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!Note to readers:
|bgcolor(pink): This is a work in progress from the [[Early Years Parenting Unit (EYPU)|02. Introducing the EYPU]] team at the [[Anna Freud Centre]] - please bear with us as this manual takes shape over the course of 2015. It will form the basis of locally adaptable wiki manuals (see [[tiddlymanuals.com|http://tiddlymanuals.tiddlyspace.com]] for more details) that teams trained at the AFC will be able to set up - allowing them to build on this content and adapt it for local circumstances, and as a way of recording local learning. |
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!Welcome! What is this?
This is an evolving [[manual|About this manual]] of practice for the [[EYPU|02. Introducing the EYPU]] based at the [[Anna Freud Centre]].
There is material here that is BEING AUTHORED. It is arranged in a number of different ways, and will become clearer and better signposted as the months go on.
Please access the current version of the manual here <<tag Contents>>
To access an earlier version of the manual, please look here <<tag Introduction>> <<tag [[Service Philosophy]]>> <<tag [[Theory into practice]]>> <<tag [[Service Organisation]]>> <<tag [[Risk Management]]>>
For technical help on this manual see:
<<tag [[Technical help with this manual]]>>
''License''
The material on this website is [[licensed|License]] to the [[Anna Freud Centre]] under a [[Creative Commons Licence|http://creativecommons.org/licenses/by-nc/4.0/]].

From the start, the primary effort must be to join the existing child welfare system with the explicit intention of working in an [[integrated|Integration]] way with statutory agencies, specifically [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]]. Crucially, this means that a) there is a genuine sharing of [[risk|Assessing risk]] between statutory agencies and the [[EYPU|02. Introducing the EYPU]]; and b) continual efforts are made actively to address potential splits between agencies. As with all aspects of the programme, the principles to bear in mind are to maintain a [[good mentalizing|Good mentalization]] stance and to work towards creating and maintaining a [[mentalizing system|Mentalizing system]].
Setting up an EYPU requires the following steps:
[[Identifying funding]]
[[Establishing relationships with partner agencies|Establishing relationships]]
[[Choosing premises]]
[[Recruiting staff]]
[[Publicising the EYPU]]

While it is important that staff members have a solid [[sense of authority|Sense of authority]], they will need to be able to manage their own needs to be controlling or to take charge of decision making. People with personality difficulties typically have very poor relationships with [[authority|Authority]], usually perceiving authority figures as being persecutory, coercive, malign, and untrustworthy. Consequently, parents are likely to respond badly to being 'told' what to do, no matter how worthy staff feel their decisions might be. By actively promoting a reflective, collaborative approach to decision making in the community, families can start to develop a more benign, productive relationship with authority. In addition, parents become active participants in the therapeutic community rather than being passive recipients of a service. This helps to encourage and reinforce personal responsibility as well as provides families with the opportunity of developing [[good mentalization|Good mentalization]] skills in interpersonal functioning.
All aspects of community life should be approached using a [[mentalizing stance]]. These include:
*maintaining the day unit
*cooking and lunch time
*purchasing equipment
*planning external and internal activities (birthdays, celebrations)
*planning leaving ceremonies
*planning the Summer programme to accommodate [[older children in the family]]
Staff and parents meet to discuss issues which have been raised in order to try and find a way of addressing and, where possible, changing things in order to meet the communites often changing needs. [[Parent-focused group therapy|Parent-focused group therapy]] or [[group therapy|Group therapy]] for parents tend to be the most appropriate forums for these discussions.
//Example:
Staff and a few parents noticed that some families were leaving the unit at lunchtimes. Lunch is an important part of the therapeutic community programme because families and staff sit alongside each other engaging in an ordinary daily activity. Parents and staff discussed this issue in the [[parent-focused group therapy|Parent-focused group therapy]] and parents agreed to either prepare food at home or bring food into the unit to cook. Parents also thought that the children ought to eat at a separate table to help them develop their relationships and feel part of their own group. Therapists wondered whether this might be parents' way of avoiding being with their children at lunch and explored this with parents. Parents did not agree with this and the community decision was to trial this.
Although attendance improved, the children quickly became unruly at their unsupervised table. Staff and parents discussed ways of resolving this and parents decided that one parent should sit with the children at lunch time. However, parents complained of missing out by being separated from the rest of the group and could think about how the children's behaviour might have been a similar reaction. The community decided to reintegrate the children and both attendance and the children's behaviour improved.//

An Early Years Parenting Unit (EYPU) is a Mentalization-based [[multi-family|Multi-family work]] [[day treatment programme|Day programme]] for families involving parents with [[personality disorder/difficulties|Personality Disorder/Difficulties]]. All families have children under five years subject to a [[Child in Need|http://protectingchildren.org.uk/cp-system/child-in-need/]] or [[Child Protection|http://protectingchildren.org.uk/cp-system/initial-assessment/child-protection-plan/]] plan, or on the [[edge of care|https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/330332/RR369_Assessing_parental_capacity_to_change_Final.pdf]]. The [[aim|Aim of EYPU]] of an EYPU is to keep children safely at home via a comprehensive intervention that integrates adult and child mental health by addressing:
• the child’s developmental needs
• the parent’s personality difficulties
• parent-child relationships.
Please click the video below to hear [[Minna Daum]] and [[Duncan Mclean]] talk about the EYPU.
<html> <iframe width="560" height="315" src="https://www.youtube.com/embed/KR8pgeq-pvQ" frameborder="0" allowfullscreen></iframe> </html>
The [[EYPU was set up|Why we set up the EYPU]] to work in collaboration with [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] and Health to engage difficult families and offer a service that enables families to stay together where possible, and to intervene early to limit damage to the child’s development. As a service that integrates both child and adult mental health it follows the [[principles|EYPU Service Principles]] of offering a one-stop comprehensive treatment facility for families with complex needs.

This is a special kind of treatment manual called a TiddlyManual - get past the geeky language and do try to understand the many advantages that this kind of treatment manual offers over conventional paper, or even conventional websites.
There is a bit of learning about how to navigate it, and edit it, but it is much easier than it may seem, and you will soon see the advantages. See [[Using the Manual]] for this guidance - of which there is plenty.
There are lots of TiddlyManuals and you can see the range at another website called [[Tiddlymanuals.com|http://tiddlymanuals.tiddlyspace.com]] - which explains what they are in more depth, and acts as a signpost to the many CORE and LOCALLY-ADAPTED versions of these manuals that are now in use.

<html><a href="http://pcs.tiddlyspace.com/_space"><img src="https://dl.dropboxusercontent.com/u/198966407/Branding/Tiddlyspace/tiddlyspacecircle.JPG" align="left" style="width: 20px;"/></a></html>
# Click the tiddlyspace icon in the top righthand corner of the website
# Select [['This Space'|http://pcs.tiddlyspace.com/_space]] from the menu.
# Type in the new member's username, click 'Add member'
//Your new member must already have a tiddlyspace login. You can [[create a tiddlyspace account|http://tiddlyspace.com/]] for free.//

It is best to 'host' your images, video and audio on a separate hosting site. We use [[dropbox|http://dropbox.com]] and [[youtube|https://youtube.com]].
<html><img src="https://dl.dropboxusercontent.com/u/198966407/%5Bimages%5D%20How-to/embedimage01.JPG" align="left" style="width: 400px"/></a></html>''Embed an image''
1. Upload your image to [[dropbox|http://dropbox.com]]
2. Right click on the image file in dropbox, '''copy public link'''
4. Paste the public link into your tiddler, within this code string:
''"""<html><img src="https://yourimage.jpg"/></a></html>"""''
<html><img src="https://dl.dropboxusercontent.com/u/198966407/%5Bimages%5D%20How-to/embedvideo01.JPG" align="left" style="width: 400px"/></a></html>''Embed a video''
1. Upload your video to [[youtube|https://youtube.com]]
2. Open your video in youtube
3. Underneath the video, select 'Share', and then select 'Embed'
4. Copy the code given
5. In tiddlyspace, paste the code into your tiddler like this:
''"""<html>ADD_YOUR_EMBED_CODE_HERE</html>
"""''

I am wondering about the structure of the 'therapeutic interventions' and if it is clear enough?

Parents engage in one 90 minute session of adult focused group therapy per week. It is helpful to begin the Adult-focused group with [[explicit mentalizing|Explicit mentalizing]]. When new parents join the group, it is important to refer back to [[explicit mentalizing|Explicit mentalizing]], and more established group members can be asked to take the lead on this.
!![[Explicit mentalizing]] in groups
Parents with personality difficulties find it very hard to name and make sense of the mental states which propel them into destructive behaviours:
//•'I shoot first, ask questions later'
•'I go from 0-100'
•'I don't hang around to find out'//
Structured group work focuses on identifying and thinking about feelings and how an escalation of certain feeling states can cause thinking to fail. Parents are encouraged to give examples of times when they have lost control and the group works 'backwards', as it were, to try and identify the mental states preceding the collapse in [[mentalization|Mentalization]]. It is helpful for therapists to initially help parents to start reflecting on emotional states like shame, humiliation, helplessness, and anxiety 'from a distance' because these states can be intolerable 'in the moment'.
It is useful to introduce the 'stop, stand, rewind' technique in order to explore how a heated situation arose in the past and the feeling states underpinning destructive behaviours. This technique can be very useful in restoring mentalizing i.e. help parents to move towards more controlled, deliberate mentalization/reflection.
Group members are actively encouraged to adopt a tentative approach when reflecting on other's mental states and therapists should model this stance. [[Good mentalization]] can also be modelled when co-therapists have a different understanding about what might be going on in the group and are able to come to a joint understanding, ideally with the parents joining in. This helps parents to see that part of [[good mentalization|Good mentalization]] involves the ability to tolerate a range of perspectives.
Practically, however, this can be hard work; people with personality disturbances can treat any attempt to make sense of their minds with suspicion and anxiety and will do almost anything to prevent this from happening. In a group setting, [[deficits in mentalization|Deficits in Mentalization]] can manifest in angry diatribes and a refusal to take things seriously, which can be very difficult to punctuate with any thinking. Therapists need to monitor arousal levels in the group closely in an effort to monitor when the group slips into automatic/implicit mentalization which can be prone to [[deficits in mentalization|Deficits in Mentalization]]. The aim is to return the group to return the group to more controlled, explicit mentalizing. Therapists need to feel confident about actively addressing this - sometimes going to the extent of interrupting people in order to draw attention to how thinking is being avoided at that moment. Getting group members into reflect on what might be going on helps to restore a sense of a group trying to think and work together.
The group is used to reflect on a variety of issues with which parents are struggling can be brought to the group for help. Weekly group therapy is also an important forum for group members to bring issues which have arisen on the day unit and which need further thought and understanding. These can include:
•the management of aggression
•attendance and engagement
•departures from the unit
•relationships with [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]]
•safeguarding children and parents
•planning events including the [[holiday programme|Holiday programme]] for older children in the family

The wider aim of the project is to improve both cost effectiveness and outcomes for children at risk by enhancing statutory decision making and professional management in working with the most complex and hard to engage families. It does this in four ways:
• [[Joint management|Joint working]] of referred cases so that there is genuine Integration between [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] and Child and [[Adult Mental Health|http://www.scie.org.uk/publications/introductionto/adultmentalhealthservices/]].
• [[Assessment of Engagement|Assessment and Engagement phase]] and capacity to change in cases where parents’ poor engagement with Social Care and Health leads to delays and breakdowns in offering effective interventions and making timely decisions
• [[Consultations for social workers]] and health professionals aimed at supporting them in managing and working with their most ‘hard to reach’ families, enhancing early identification of emotional harm and more effective use of the network
• [[Training for social workers|Training for Social Workers]] and health professionals providing a framework for understanding personality difficulties and their impact on both child development and professional networks.
In [[setting up an EYPU|About the EYPU]], the principle that all elements of the service should be [[integrated|Integration]] needs to be considered, and in particular how the service will relate to the aims and requirements of other agencies, particularly [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]].
The value of the [[EYPU|About the EYPU]] needs to be evaluated not only in terms of outcomes for families who successfully complete the EYPU [[day programme|Day programme]], but also in terms of effective management and timely decision-making in relation to complex, high-risk families. Underlying this, the aim is to increase social workers' sense of confidence and competence and support their development of [[mentalization-based social work|Mentalization-based social work]].

Managing and minimising risk is a primary objective of the service. With the involvement of children there is a priority in preventing physical or emotional harm by trauma or neglect. In the EYPU service there are also the frequent risks to the physical and mental health of the parents involved, which also need to be actively considered.
<html><iframe width="560" height="315" src="https://www.youtube.com/embed/Phni18P44Ts" frameborder="0" allowfullscreen></iframe></html>
The treatment unit will need to ensure that any risk to either child or parent is assessed as fully as possible. This means risk should be formally evaluated and recorded. The formal aspect consists of interviewing the parent with the central and explicit purpose of investigating the risk. It is important that this is prioritised before other needs of the family are addressed.
A mentalizing approach will usually be needed to help the parent construct a narrative concerning the risk issue and also as a means of devising with the parent a means of mitigating the risk. This might mean devising a crisis plan, though more frequently it will mean understanding with the parent what led to the risk situation and finding ways to ensure this is not repeated. It should always be part of this process to discuss who needs to know and be informed about the risk issue such as other family members, social workers, GP's, and other health workers. It is essential that the therapist understands that risk issues cannot be part of therapeutic confidentiality and that others will need to know the situation to help mange the risk. Parents with personality difficulties can attempt to evade responsibility for addressing risk by secrecy and it becomes particularly important that there is a systemic approach with information sharing and a common determination to monitor and respond to risk.
Different issues are involved in [[assessing risk in adults]] and [[assessing risk to children|Assessing risk to children]], as the first often involves self harm, and the second involves abuse or neglect of children.

This tiddler is under development.
In relation to children, 'risk' refers to the risk of suffering significant harm.
Assessing risk to children involved with the EYPU needs to be understood and managed using the principles outlined in the [[Service Philosophy]].

After a referral from the Local Authority has been through the EYPU [[consultation|Consultations for social workers]] process, a family enters the Assessment and Engagement phase.
The assessment and engagement phase begins with an initial meeting between the EYPU key worker and the allocated social worker in order to arrive at a shared understanding of the Local Authority’s concerns and what would need to change in order for these concerns to be reduced. Next, the social worker and the EYPU therapist arrange a joint home visit to the family to discuss the referral to the EYPU. The EYPU key worker then arranges two further meetings with the family to carry out an assessment of parenting capacity, capacity to change, and capacity to engage in treatment.
The key worker will also use the assessment and engagement phase to talk to the parent/s about all aspects of the EYPU treatment programme. It is especially important to spend time explaining the aim of Mentalization Based Therapy in relation to group and individual therapy; parents tend to be anxious about the prospect of engaging in [[Group therapy]] and it is important to use this time to fully explore any misconceptions //"Group therapy is like an A.A. meeting"// and misgivings //"People will attack me/not be interested/tell other people what I say"// they might have.
If the outcome of the assessment and engagement phase is positive, i.e. if the parent is able to enter into a relationship with the EYPU clinician within which they can discuss issues of concern in relation to the child/ren, and if the family is deemed appropriate for treatment at the EYPU, a recommendation will be made that the family attends the EYPU’s multi-family treatment [[day programme]].
The assessment and engagement phase culminates with a further joint meeting with the EYPU therapist and the children's social worker to draw up a three-way therapeutic contract between Children’s Social Care (CSC), the family, and the EYPU.
!!Therapeutic Contract
The EYPU therapeutic contract highlights the following:
• The Local Authority’s concerns and desired outcomes of treatment
• The parent’s goals of treatment
• The EYPU’s conditions of treatment
The therapeutic contract is reviewed on a 3-monthly basis at a meeting attended by the family, the social worker and the EYPU key worker.

The question of authority is central to any service treating complex families, in the sense that everyone is subject to both legal and social boundaries to their behaviour, and the treating staff must negotiate how transgressions of these boundaries are to be addressed. This is a particularly difficult issue in a service where parents have transgressed acceptable boundaries to behaviour in relation to both children and others in many respects.
<html><iframe width="560" height="315" src="https://www.youtube.com/embed/CyCb31rBBkA" frameborder="0" allowfullscreen></iframe></html>
A key feature of personality disturbance is that an individual acts at times in a manner that is damaging to themselves, damaging to others, or both. [[Mentalization]] when developed as a reflective process in a parent can help manage the feelings and impulses leading to these acts and limit them. However, this takes time so limit setting is necessary to reduce destructive behaviour. Limit setting also sets the conditions by which a parent is required to manage their impulses other than by action. This is no different from the way a parent sets boundaries on their child's behaviour before helping them manage their frustration. Parents who cannot limit their own behaviour will usually find setting limits with their children very difficult.
Limit setting requires the exercise of authority. This can be done both formally as in the chld protection procedures of Social Care, and therapeutically in the demand a therapist makes on a parent to change and limit their destructive behaviour. The latter can usually only be done when some measure of security has been developed between therapist and parent; this means some belief in the parent of the benevolence of the therapist. While developing this relationship with a parent the therapist has to rely on the formal limit setting of child protection procedures and should not make the mistake of distancing themselves from Social Care in a misguided belief that this would help convince a parent of their good intentions.
It is important that there is an [[Integration]] of the use of authority with [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]]. In addition, each therapist needs to develop a coherent and solid [[sense of authority|Sense of authority]] in themselves that is at the same time linked to and supported by both the team and the wider network.

In most browsers, you should be able to bookmark specific pages in the usual way.
But for some older browsers, you may not be able to use your ordinary 'Bookmark' button in your browser (if you do, this may only save a bookmark for the general homepage). In this case, use the <<permaview>> button in the top right corner of the screen, before bookmarking. This will generate a usable link in the browser address bar for the page you are currently viewing, and then you can go ahead and bookmark the page in your usual way.

It's relatively easy to make your version of this EYPU manual suit your organisation's branding, by changing the colour palette:
#Choose two key colors (primary, secondary)
#Pick four shades of each colour (pale, light, mid, dark)
#Enter the colour codes into the [[ColorPalette]] tiddler
Hello?
You may find [[this html colour-picker website|http://www.w3schools.com/tags/ref_colorpicker.asp]] helpful. Just pick your mid-level colour, and the website will generate a gradient of pale to dark shades in that colour and output the corresponding colour codes.
*the tertiary colour (grey) the foreground colour (black) and the background colour (white) are the base colours for most items on the site. We recommend you leave these as they are, unless you especially want a psychedelic colour scheme (in which case, go for it!).

First, you'll need to upload your logo to an ''external file-hosting site''. We use [[Dropbox|https://www.dropbox.com/home]]. You could also try [[Flickr|www.flickr.com/]], [[GoogleDrive|https://drive.google.com/]] or [[Picasaweb|https://picasaweb.google.com]]. Once uploaded, you will need to copy the public URL link to your image into Tiddlyspace.
Next, go to the [[SideBarTabs]] tiddler to edit the Sidebar menu on the right (where the logo is embedded). Simply replace the image link to the Anna Freud Centre logo with the link to your own image. It should look like this:
''"""<html><img src="https://yourimage.jpg" style="width: 280px;"/></a></html>"""''
If you want people to be able to click your logo and to be taken to your organisation's website, then it should look like this:
''"""<html><a href="http://yourwebsite.com"><img src="https://yourimage.jpg" style="width: 280px;"/></a></html>"""''
!!!!!See also: [[How to add images, video or audio|Add images, video or audio]]

The title and subtitle of your space are visible to visitors and are also displayed in your browser's tabs. Click on the [[SiteTitle]] and [[SiteSubtitle]] tiddler links to make changes.

When parents are engaged in group therapy. 2 therapists on the floor working alongside volunteers. Group games.

You can choose which page you want to appear as your homepage (front page). Just go to the [[DefaultTiddlers]] tiddler and enter the name of the tiddler you want as your homepage. Remember your double square brackets.

!Principles
*The [[EYPU|About the EYPU]] needs to be set up as a [[Therapeutic community]]. This means that families attending the unit need to feel a sense of ownership and belonging, and potentially to be involved in the creation of the therapeutic space.
*Geographically, it needs to be located within or as near as possible to the community it serves.
*It needs to be non-stigmatising and homely.
*It needs to feel like a safe space for families; this means that the rooms should be dedicated to use by EYPU families and staff.
*It needs to include facilities available in a home, so that all the ordinary aspects of daily life can be thought about. This includes cooking, washing, outdoor space etc.
*It will need space for both group and individual therapeutic work, and space for family and multi-family work.
*It needs to be safe for under-5 children.

The EYPU is based on a [[therapeutic community|Therapeutic community]] approach. This means that people in treatment are not just passive recipients, they are active participants in their treatment. In others words, the service is co-produced between staff and service users. While understanding the importance of [[authority|Authority]], a fundamental aspect of the model is the way in which parents themselves shape the running of the Unit, whether at the [[morning meeting|Morning meeting]] to decide what things they want to focus on, or participating in recruitment processes or talking about issues in the way that the place is run generally.
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Graduates of the EYPU programme are actively encouraged to become involved in running the EYPU programme, includin participation on the [[Expert Advisory Board]].

There is universal agreement among professionals working with complex cases/personality disorders that in order to be effective, clinical services must be comprehensive, that is they must address all the problems that the family or individual presents.

Social workers are offered weekly consultations with [[EYPU|02. Introducing the EYPU]] clinicians on cases where they feel 'stuck'; such cases do not have to involve parents with [[personality disorder/difficulties|Personality Disorder/Difficulties]]. The purpose of such consultations is to build up a genuinely collaborative relationship with Children's social care within a mentalizing framework.
Consultations are focused on how they felt and thought about the case, how their own emotional responses to those cases and what they were thinking and feeling in relation to them. In other words, the relationship with social care is not just mentalizing about the case but also about them as workers with the case, which was built into whole relationship from the beginning.
In addition, where families are identified as appropriate for the EYPU but fail to engage, EYPU staff offer consultation to social workers and the professional network in managing these complex cases.

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The [[structure and frequency|Structure and frequency of the day programme]] of the day programme will be decided by the managers of the project, initially in consultation with the staff, but with the continuing possibility of modifying the programme together with all participants including the families themselves.
Important elements of the therapeutic day programme will include:
[[Multi-family work]]
[[Therapeutic community]]
[[Individual Therapy]] for parents
[[Group therapy]] for parents
*[[Adult-focused group therapy]]
*[[Parent-focused group therapy]]
[[Parent-child work]], including [[video feedback|Video feedback]]
[[Children's groups]]
[[Holiday programme]] to include [[older children in the family|Older children]]
[[Graduate groups]]
[[Delivering the day programme]] is dependent on a staff team with a range of therapeutic expertise and personal qualities that enable them to offer a range of therapeutic inputs over the course of a day.
[[Risk management|Risk Management]] is a central concern of the [[EYPU|About the EYPU]].

[[Introduction]]

The capacity to mentalize can be very uneven in any individual. People can be very good at mentalizing, say, about others, but poor in mentalizing about themselves. For communication to be effective, particularly in a therapeutic setting, it is important that there is a recognition of any deficits in mentalization there may be in the client. There may be global deficits in relation to particular states of mind such as anger or sadness, such that these will be immediately avoided and not thought about. There may also be temporary deficits such as a 'switched off' state where all feelings are suppressed and emotional communication is not possible. In these deficit states it is important that there is an attempt to make explicit in mentalizing terms the client's inability to mentalize at these times. So for example a therapist may say they are guessing that someone is switched off and feeling very little, or the therapist may say they get the impression that the client never sees themselves as being in an angry state.
An individual's capacity to mentalize can fluctuate over time, so for example anyone in a highly emotional state is likely to have a poor ability to mentalize and may regress to prementalizing modes of thinking. These include: pretend mode; psychic equivalent mode; and the teleological mode.
!!Pretend mode
In pretend mode thinking, mental states are decoupled from emotional reality; mental states are spoken about with little accompanying emotion. This manifests as intellectualizing, using jargon and 'psychobabble' and can have the effect of boring and/or confusing the listener.
The danger of pretend mode is that it lulls both patient and therapist into a fantasy of understanding that has little experiential contact with reality. Genuine reflection and understanding becomes lost.
//Example: during the [[Assessment and Engagement phase]], a mother who has real problems negotiating with professionals and accepting advice about caring for her baby, talks at length and very knowledgeably about personality disorder and deficits in mentalization. When asked to say how this affects her relationship with her daughter, the mother says, "I need to mentalize in my relationship." The therapist feels that the mother is regurgitating a text book; there is no sense of how any of this actually relates to her functioning as a parent. The therapist needs to make a contrary move; the patient is emotionally distant so the therapist needs to try and get some emotional closeness between them by up-regulating the affect. The therapist does so by sharing her own state of mind with the mother, asking her to say it all again but without any of the "big words." The mother immediately becomes anxious, saying, "I don't know. I don't know what you want me to say." Therapist and mother are then able to reflect on the mother's anxiety about "not knowing" and how this pushes her to be "all knowing" which, in turn, causes conflict with professionals.//
!! The Psychic equivalence mode
The psychic equivalenct mode is one of the prementalizing modes of thinking in which reality is equated with mental states; mental reality = outer reality. Extreme examples of psychic equivalent thinking include: posttraumatic flashbacks and paranoia.
Psychic equivalence thinking is characterised by an intolerance of alternative perspectives because the capacity to represent mental states in the self and in others is absent. So, someone who is operating in this mode will find it very difficult to recognize that another person might be experiencing a different set of thoughts and feelings from those which are being inflexibly attributed to them at that moment.
//Example: In [[Adult-focused group therapy]] a mother accuses social workers of just wanting to take children away from their parents saying, "They get a bonus for every child they remove." All the other members agree with this and the group very quickly becomes caught in the grip of psychic equivalent thinking, turning on the therapists for colluding with CSC, and calling them "Social Services bitches." Feeling attacked and on the ropes, one of the therapists tries to reason with the group, pointing out that CSC would hardly refer them for treatment if their sole objective was to remove their children. This intervention is roundly treated with contempt, with one member mocking the therapist for her naiveté; "Oh please! They have to PRETEND to show the Court they're trying to help but actually they're already filling in the adoption forms." The other therapist sees that there is nothing to be gained in trying to argue the point with one group member stuck in psychic equivalence mode, let alone 9. He stops the group, asking them to go back/rewind to the start of the discussion (when mentalization failed) and asks the group how they cope with this knowledge, i.e., that their children aren't safe with them and liable to be removed at any moment. This stops the argument, as it were, and the group is in more of a position to reflect on their extreme anxiety, and mistrust of professionals.//
!!Teleological mode
In this mode, mental states are expressed in goal-directed actions instead of explicit mental representations, like words. When deliberate self-harm is used as a way of communicating extreme emotional pain, the person is operating in the teleological mode of mentalization. People caught up in this mode also view direct action on the part of others as being the only way of demonstrating care, and commitment. The wish for action can be very powerful and can push therapists into action (filling out forms, writing letters, un-boundaried contact) rather than reflection.
//Example: a mother demands that her key worker arrange childcare for her so that she can attend a hospital appointment. When the key worker says that he can't do this and tries to help the mother to think about alternatives (re-arranging the appointment, enlisting the help of friends, paying the child minder for an extra session) the parent becomes furious and threatens to leave the EYPU because the key worker does not care about her because he is refusing to arrange(and pay for) extra child care. The key worker almost says that he will accompany the mother to the hospital appointment and look after her child while she is being seen. Instead of being pushed into this action in order to assuage his own feelings of guilt and helplessness, he holds fast by continuing to validate the mother's own feelings of helplessness and panic, trying to keep both of them thinking about ways to resolve the problem. After putting the phone down on him a number of times, the therapist waits for the mother's arousal to diminish before phoning her back the next day. Calmer, the mother is now able to have a more productive and reflective discussion with the therapist, the outcome of which is re-arranging the appointment (which is non-urgent) to a time when her child is at nursery. During [[Individual Therapy]], they rewind to the feelings of helplessness and panic which overwhelmed the mother's capacity to mentalize and sort the situation out with relative ease.//
!!Distorted/bizarre mentalizing
This occurs when mental states in the other are denied, undermined, or distorted.
//Example://

To deliver the day programme will require a [[staff team|Recruiting staff]] with a range of therapeutic expertise and personal qualities that enable them to become an integrated team offering a wide range of therapeutic inputs in a number of ways over the course of a day. The staff will need to be supported in doing this by a high level of [[supervision|Supervision]] in which they are offered both [[individual supervision]] and [[group supervision]], together with a [[reflective group|Reflective group for staff]] for all members of the staff team. These activities require protected time apart from the [[day programme|Day programme]] itself, and at least half a day per week will be needed for this.
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A system for [[record keeping]] and [[evaluation|Evidence of effectiveness]] of the service needs to be devised in a succinct and practical fashion such that sufficient evidence is obtained without disabling the staff with an overload of administration.
Throughout a family's involvement with the unit, the staff will maintain their [[integrated working|Integration]] with other agencies. This will take place through [[joint reviews]] with [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] and involving the participation with other agencies, particularly [[General Practitioners]]. This relationship will also be maintained through [[consultations|Consultations for social workers]] and [[training|Training for Social Workers]] and for social workers and other allied professionals.

As trust in the community grows and parents increasingly expose themselves to social pressures, problematic behaviours and/or interactions on the day unit can be explored via other families' views and perspectives. This is particularly helpful for parents with personality problems who, given their difficulties with authority, typically find it easier to 'take it' from their peers rather than from professionals. In addition, parents develop the capacity to generate and consider a range of perspectives to a particular issue, which is a facet of [[good mentalization|Good mentalization]].
//Example: a therapist reminds a parent who is relatively new to the unit that she should not be using her phone during parent-child time on the day unit. The mother complies and the therapist moves to engage with another family. During [[adult-focused group therapy|Adult-focused group therapy]], it emerges that after the therapist left the situation, the mother swore audibly and said that she would hit the therapist. The families comment on how they experienced her behaviour, expressing their concerns about the fact that the children on the unit were exposed to aggression and swearing. Although the mother is visibly stirred up by the group discussion, she is able to participate in the discussion and can start to be reflective about the impact that she might have had on the children in general and her child in particular. This mother, who has routinely dismissed any issues and concerns about her parenting during the [[assessment and engagement phase|Assessment and Engagement phase]], is able to say to the group 'This is why I'm here...it's my temper'. The therapists running the group remind the group that any threats of violence will be treated seriously and this is reinforced during individual therapy with the mother who understands that if she makes any sucjh threats in the future, the police will be called.//

A mutli-family approach with these families has numerous benefits. Families learn that they are 'not alone' and that other families have similar problems. This helps to reduce a sense of isolation and stigmatisation that families can carry with them as a result of having Children's social care involvement in their lives. Families have the opportunity of developing friendships out of which social/support networks emerge which can continue outside of the treatment unit. This also permits families to make the transition from the multi-family group to local groups for parents in the community.

This online manual is intended as a resource for health and social care professionals. While the manual acts as a guide to setting up your own [[EYPU|About the EYPU]], [[Training is available|http://www.annafreud.org/courses.php]] from the [[Anna Freud Centre|http://www.annafreud.org]], and is recommended before the material in this manual can be used safely. At all times, practitioners remain responsible for their own clinical practice.

The EYPU provides an [[integrated|Integration]], comprehensive [[day treatment service|Day programme]] to families where parents are experiencing [[personality disorder/difficulties|Personality Disorder/Difficulties]]. It is based on an practice called [[mentalization|Mentalization]]. Fostering [[good mentalizing|Good mentalization]] is dependent on co-producing the service with service users. This achieved via a [[therapeutic community|Therapeutic community]] approach which encourages shared decision-making about how the [[service functions|Service Organisation]].
When [[setting up an EYPU|Setting up an EYPU]], the following principles are fundamental to all aspects of [[service organisation|Service Organisation]]:
[[Integration]]
[[Comprehensiveness]]
[[Mentalization]]
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[[Co-production]]
[[Authority]]
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[[Assessment|Assessing risk]] and [[management of risk|Risk Management]]

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A multi-family approach encourages parents to move from a position of 'helplessness', where things are done 'to them', to one of 'helpfullness', where they take responsibility for what happens around and for them. Although the structure and frequency of the [[day programme|day programme]] is decided by the staff, there is an ongoing possibility of families and staff modifying the treatment programme together. This fosters a sense of agency in families who frequently complain of feeling disenfranchised by the systems around them.
//*'The Government own you...they decide where you live, how much money you can get and you have no say.'//
//*'We have no rights...they can just take our kids away whenever they want.'//
//Example: when the EYPU day programme was initially devised by therapists, [[adult-focused group therapy|Adult-focused group therapy]] was scheduled to take place on a Monday with parents attending [[parent-focused group therapy|Parent-focused group therapy]] on a Wednesday, in the afternoon. Some months into the treatment programme, parents voiced their dissatisfaction with this arrangement, saying that they felt that they needed help to think about their parenting difficutlies which had arisen over the four days outside programme time so that they could put this thinking into practice during [[parent-child work|Parent-child work]]. The community made the decision together to change the schedule so that the parenting group took place on a Monday morning, which would give parents the entire afternoon and the morning of the Wednesday to use their time with their children more productively. The adult group was moved to a Wednesday afternoon.//
Families are actively engaged in discussions and negotiations about all aspects of community life and share the responsibility for creating the environment around them. To this end, they consult on the day-to-day running of the unit, participate in the preparation and cooking of community meals, arrange on- and off-site multi-family activities, organise a variety of celebrations (birthdays, graduations, other festivals), and are involved in [[recruiting staff|Recruiting staff]]. In addition to developing a sense of agency and pride when things go well, families learn to shoulder the responsibility for what doesn't go so well and have to think about how things might be improved in future.
//Example: during the [[holiday programme|Holiday programme]], families decided to organise a barbeque for a 'reunion' day - a day when graduates of the programme are invited along with current families and their older children. Families spent some time thinking about and planning the day, allocating each other to a variety of tasks, including entertaining the children and cooking. While the day itself proved popular, some difficutlies were encountered: parents misjudged the timing of the barbeque, which meant that children were clamouring for food which was finally presented in an undercooked state; 'experts' began to weigh in which meant that children were left unattended; and the designated cook's older boys became increasingly dysregulated and aggressive. Parents needed to think about ways of managing these difficulties for future events and came up with a variety of possibilities including: starting the babeque earlier; having 'back up' food in case of disaster; sticking to their allocated tasks so that the children are not left to their own devices; having a different cook so that the mother in question can attend to her boys.//

The primary relationship needs to be with [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] (CSC) in the Borough(s) or Local Authorities that will be served by the EYPU. Relationships also need to be established with Adult Mental Health, CAMHS, and General Practitioners, but the first task is to identify an 'owner' or 'champion' within CSC. This is likely to be a (very) senior manager within the [[Child in Need|http://protectingchildren.org.uk/cp-system/child-in-need/]] service, where most referrals are likely to originate.
The role of the 'owner' is an important one. The EYPU model may be unfamiliar, specifically in its insistence on working in a genuinely integrated way with CSC. It is therefore very important that the 'owner' comes to an understanding of the model through discussion. Having established this understanding, his/her main roles will be as follows:
*To draw up and sign a Service Level Agreement with the EYPU;
*To communicate the aims and ethos of the EYPU to senior managers and frontline Social Workers;
*To [[raise the profile of the EYPU|Publicising the EYPU]] as a resource so that it is known and understood by Social Workers within the Borough or Local Authority;
*To act as gatekeeper for CSC referrals;
*To support the setting up of [[training for social workers|Training for Social Workers]] and [[consultations for social workers|Consultations for social workers]];
*Clarifying [[Referral Pathways]] to the EYPU.
Beyond this, the most important way to establish relationships within the Borough or Local Authority is to demonstrate to statutory professionals, primarily Social Workers, that the EYPU responds in a flexible and accessible way to work //alongside// frontline workers in thinking about and managing their most difficult cases. This model of working sets up a different relationship between the EYPU and CSC from the traditional Social Care/Health relationship, in which difficult cases are handed backwards and forwards between agencies like 'hot potatoes'.

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In this video, a father discusses the impact of one-to-one work with his son and the difference that coming to the EYPU has made to his parenting, specifically his ability to offer emotional support and the improved bond with his son.
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Graduates of the EYPU programme are actively encouraged to become involved in running the EYPU programme. They are invited to be service user representatives on the EYPU Expert Advisory Board, which comprises a range of professionals (Social Work Operational Managers, EYPU Project Leads, representatives from Adult Mental Health and CAMHS Services), participate in recruitment, and assist new families to engage in the treatment programme.

Whenever we are engaged in the process of thinking or talking about our emotional states and our thoughts, or those of another, we are engaged in explicit mentalization. Explicit mentalizing involves a conscious, deliberate attempt to reflect on and talk about one's own or another's mental states.
While implicit and explicit mentalizing represent the two poles of mentalizing, they are not mutually exclusive. People can move between the two poles and can also be engaged in both simultaneously e.g a therapist can be explicitly reflecting on a parent's state of mind while still being aware of more unconscious, intuitive processes at work in the room.
//Example: during an individual session, a parent is demanding that a therapist call her a taxi immediately because she wishes to go to the bank. The therapist knows that the parent is perfectly able to go to the bank after programme hours or in the intervening days when she is not required to attend and is concerned that the parent and her child will miss their therapy if they leave. Although the therapist spends some time explicitly reflecting on what she imagines must be the parent's anxiety and how this might be managed in a more considered way, the parent remains calmly implacable, insisting that the therapist call a taxi immediately. The therapist becomes aware that she is starting to feel anxious herself and recognizes that this is in response to her fear that the parent might attack her. This intuitive feeling is confirmed when the parent leans forward and tells the therapist in a quiet voice that if she does not comply with her demands, she will see a 'different side' to her. The therapist is able to manoeuvre herself out of the situation. Later, when both parties' mentalization has been restored, the therapist mentalizes the transference, making explicit her intuitive response to the parent who agrees that she had been feeling very angry at the time. The parent and the therapist then try to understand what was happening between them in their relationship at that time. The parent acknowledges that she was indeed attempting to intimidate the therapist because she felt as if this were the only way to get her needs met. Further work is done in the session to try and understand how and why the parent has come to resort to this way of managing her interpersonal relationships when she feels anxious and under stress//
!!Explicit mentalizing in Group Therapy

Parents are encouraged to act as 'consultants' to each other. Initiating conversations between parents about a particular problem not only helps parents to take ownership of problem-solving, it also promotes an environment where parents consult with each other about their children and what might be going on for them. This creates an environment of multiple suggestions and reflections which assists in the development of [[good mentalization|Good mentalization]].
//Example: a mother who struggles to read and respond to her infant's cues is watching him while he plays by himself on the floor. A therapist asks another parent to comment on what she thinks the baby's signals (outstretched arms and smile) might mean. The parent wonders whether the baby wants his mother to come down to the floor to play with him or whether he wants to be picked up. The mother sits down behind the baby and the other mother suggests that she sit facing him so he can 'see you'. The baby continues to reach out for his mother and she decides to pick him up. He responds by burrowing into her neck. The mothers laugh at this, commenting on the fact that they have 'worked it out' and they continue the conversation, facilitated by the therapist, about ways of trying to figure out their (non-verbal) children's behaviour. The first mother feels supported by the other mother and more open to reflection about her child's state of mind.//

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|AFC|Anna Freud Centre|
|AMBIT|Adolescent Mentalization Based Integrative Treatment|
|CAMHS|Child and Adolescent Mental Health Services|
|CAS|Court Assessment Service|
|CBT|Cognitive Behaviour Therapy|
|CPS|Child Psychotherapy Service|
|IAPT|Improving Access to Psychological Therapies|
|MBT|Mentalization Based Therapy|
|MBT-F|Mentalization Based Therapy for Families|
|Mentalization|Mentalization is the ability to perceive and to communicate one's own mental states and those of others - or the ability to be 'mindful of minds.' The term is loosely interchangeable with intersubjectivity and theory of minds. Mentalization Based Therapy encourages mentalization in order to improve intimate relationships|
|Neuroscience|The scientific study of the brain, its structure and its functioning|
|PIP|Parent Infant Project|
|Psychoanalysis|A therapeutic method for treating personality/behavioural disorders that brings the unconscious fantasies and desires of the sufferer into their conscious mind.|
|Psychodynamic|Psychodynamics are the study of the interrelated parts of the mind, emotions and psyche - and how they influence each other and change. Psychodynamic psychotherapy is a form of psychotherapy that incorporates a variety of (interrelated) techniques according to the client's needs.|
|RCT|Randomised Control Trial. A scientific procedure used to test medicines or medical procedures. An RCT is also used to test new psychological therapies.|
|UCL|University College London|

Good mentalizing happens when one tries to reflect on one's own and other people's thoughts, feelings, motivations, and desires i.e. mental states. It involves an ability to be in the other's shoes without stepping out of one's own and also being reflective about one's own contribution to the relationship.
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Good mentalizing acknowledges the inherent opaqueness of another's mental states i.e. one can never be absolutely certain about what someone else is feeling or thinking without asking. Consequently, good mentalizing necessarily involves a curious, tentative stance when trying to make sense of another's mental state. It means having to face 'getting it wrong' and being open to the possibility that one’s mind may be influenced, changed and enlightened by learning about another’s mind.
In general, good mentalization includes:
*A relaxed, flexible outlook; the person is not “stuck” in one point of view to the exclusion of others
*Playfulness and humour that engages rather than distances
*Recognises that problems can be solved by give-and-take/turn taking
*Two way communication
*Ownership of behaviour and feelings rather than the sense of it “happening to” them
*Curiosity about other people’s perspective
*Belief that minds can be changed
*Forgiveness.
The [[mentalizing therapist|The mentalizing therapist]] is curious, uncertain and prepare to change their mind.

Once a family has completed the intensive 18-month treatment programme, the parents are invited to attend monthly graduate/leavers' groups. This ensures that families maintain contact with the unit to which they have formed an attachment over the course of their treatment.
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Groups are facilitated by two therapists who leave it up to the families to decide what they wish to bring for help. Typically, parents use some of the time to 'catch up' with each other, talking about how they are getting on post-treatment at the EYPU. They also use the time to think about any difficulties which have arisen in their lives and how these might be addressed.
Graduates of the EYPU programme are actively encouraged to become involved in running the EYPU programme. They are invited to be service user representatives on the EYPU Expert Advisory Board, which comprises a range of professionals (Social Work Operational Managers, EYPU Project Leads, representatives from Adult Mental Health and CAMHS Services), participate in recruitment, and assist new families to engage in the treatment programme.

[[Mentalization-based therapy|Mentalization-based therapy]] combines both group and individual [[psychotherapy|http://www.psychotherapy.org.uk/16/information/what-is-psychotherapy]] . In addition to one session of [[individual therapy|Individual Therapy]], parents participate in one session of [[adult-focused group therapy|Adult-focused group therapy]] and one session of [[parent-focused group therapy|Parent-focused group therapy]] per week.
Parents with personality disorders tend to have strong fears and anxieties about group therapy because they are being asked to reflect on their own minds and the minds of up to 10 other people in the room. This can provoke intense and confusing mental states that can be extremely difficult to mentalize and [[deficits in mentalization|Deficits in Mentalization]] quickly arise.
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It is important to prepare parents for group therapy during the [[assessment and engagement phase|Assessment and Engagement phase]], exploring any worries and fears that they might have about this approach. Therapists need to make it explicit from the outset that the aim of group [[psychotherapy|http://www.psychotherapy.org.uk/16/information/what-is-psychotherapy]] is to help parents reflect on their thoughts and feelings and those of the people around them in order to help them understand and manage stressful situations, including parenting, more effectively. The aim of therapy, therefore, is not to seek insight but to enhance mentalizing and to restore it when it fails. Therapists should use individual therapy sessions to explore parents' experience of group therapy with the aim of helping parents to take any difficulties arising out of group therapy back to the group for further help and reflection.
Therapists need to monitor anxiety levels closely in order to prevent the group from either stagnating due to low levels of arousal or from spiralling out of control due to unchecked anxiety resulting in a regression to [[prementalizing]] modes of thinking. In practice, this can be very challenging work, especially if the group becomes united against the 'enemy'/therapist when in the grip of concrete [[psychic equivalent]] thinking. It is advisable, therefore, to have two therapists running a group because it can be very demanding for one therapist to keep thinking in a maelstrom of intense emotions and [[poor mentalizing|Deficits in Mentalization]].
While peer confrontations contribute to a productive group therapeutic process, therapists should always have an eye on maintaining physical and emotional safety in the group. Therapists need to feel confident about their [[sense of authority|Sense of authority]] to set limits and should address transgressions quickly in order to protect the group from the threat of collapse. Practically, this can be achieved by working actively with parents to draw up a list of agreed rules and norms of behaviour and returning to these periodically when new members join the group. These might include:
*Allowing people to speak without interrupting
*No mobile phones
*Attending punctually
*Trying to stay in the group
*No threats or acts of physical violence
*No verbal abuse (swearing at someone as opposed to swearing about something)
The group and therapists should have a clear, shared understanding that the therapists will need to exercise their [[authority|Authority]] in the event of serious boundary transgressions. For example, the police will be called if a parent makes a direct threat of physical harm or death.
The use of mobile phones is an ongoing difficulty which needs constant monitoring and therapists should be prepared to use the group to address this issue. Therapists are unlikely to be successful in 'banning' phones in an autocratic way; rather, it is more helpful if the group thinks together about how the use of mobile phones affects people's capacity to attend to each other.

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The [[EYPU|02. Introducing the EYPU]] offers a treatment service for parents with [[personality disorder/difficulties|Personality Disorder/Difficulties]] and their children under five years old. As a result, older children in the family are not able to attend the full treatment programme because they are in full-time education. However, given the importance of attending to the whole family in a [[multi-family therapy|Multi-family work]] approach, older children attend the treatment programme with the rest of the family during the school holidays.
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The holiday programme is an important way of encouraging families to engage in multi-family activities; reduced staffing levels and more children pushes the community to use its resources more creatively and more effectively in order to meet everyone's needs. This is particularly helpful for parents struggling to manage with more than one child in the family and promotes a community approach to facing the challenges of parenting when school's out. Things to consider include:
[[Staffing during holiday periods]]
[[Older children]]
[[Planning the holiday programme]]

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The EYPU was funded via a grant from the [[Department for Education|https://www.gov.uk/government/organisations/department-for-education]].
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Parents will have one session of individual mentalisation based therapy per week with their allocated key worker. When couples attend the unit, it has been helpful to alternate individual therapy with couple work in order to help parents address the way in which they manage their relationship and co-parenting.
!!Aims of therapy
*To enhance the capacity for [[mentalization|Mentalization]]
*To manage emotional states by facilitating the recovery of mentalization
*To promote a mentalizing attitude to relationships and problems
*To instill doubt where there is rigidity ('black and white' thinking)
*To promote curiousity about the parent's own mental states and those of others.
!!Prioritising
Given that people with personality disturbances can find it very difficult to prioritise - a mental activity involving both explicit and implicit mentalizing - they can present a range of issues in a chaotic way. One of the ways in which the therapist can help to restore mentalizing is by agreeing a hierarchy of issues, in order of importance, to be addressed within sessions. Therapists should always have the [[assessment of risk|Assessing risk]] as the top priority in their minds.
//Example: in a session, a parent talks about recent deliberate self-harm, suicidal ideation, bulimia, mood swings, volatile behaviour, alcohol and cannabis use, and difficulties managing her three young boys. The mother insists that she needs more of the therapist's time in order to help her deal with her depression and suicidal ideation. Expressing empathy about the mother's predicament, the therapist nonetheless needs to ascertain the risk to the children. The therapist establishes that the mother's drug and alcohol use is significantly exacerbating her existing difficulties and is having a serious impact on her capacity to parent her children safely. After exploring this with the mother during the session, it becomes clear that the mother's risk of suicide remains high and that she has little motivation to address her substance misuse issues. The therapist and the mother are able to agree that the therapist needs to contact the children's social worker as a matter of urgency. The social worker and the therapist spend some time with the mother to try and put a plan in place which will minimise the risk to the children and to her. To this end, the children are placed in temporary foster care and the mother is offered a place in a residential crisis centre in order to manage the risk to herself. //
!!Confidentiality
Parents are made aware from the outset that the key worker will share information with the team who will keep this confidential unless issues of risk arise in which case, information is shared with CSC and other relevant agencies. The therapist will not disclose session material to the group. However, if matrerial seems to be relevant to group therapy, the therapist will encourage the parent to bring it to the group for further help.

Professional networks around people with [[personality difficulties|Personality Disorder/Difficulties]] are typified by fragmentation, confusion of roles, disagreements between professionals on the nature of the concerns and how to address them, and often open or covert conflicts. This leads to paralysis in professional networks and delays in decision making, while interventions are piecemeal and ineffective. In cases involving risk to children, there is often an unhelpful separation between the professional holding statutory authority (the child's Social Worker) and other professionals.
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A fundemental principle of the [[EYPU|About the EYPU]] is to combat this fragmented approach to complex families and to adopt instead a wholly integrated approach in which there is no separation between the clinical service offered to the family and statutory authority held by [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] and other agencies such as Health.

This [[manual|About this manual]] provides you with a step-by-step guide to setting up your own [[Early Years Parenting Unit (EYPU)|Why we set up the EYPU]]. The Unit is based on an approach called [[mentalization-based practice|Mentalization-based practice]]. Working in collaboration with [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] is fundamental to its effectiveness. The manual will introduce to why EYPU's are needed, the therapeutic [[day programme|Day programme]] at EYPU and the difference that it makes to families where parents are experiencing [[personality disorder/difficulties|Personality Disorder/Difficulties]].
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''Who is this manual for?''
This manual is for anyone interested in setting up their own [[early years parenting programme|http://www.annafreud.org/data/files/EYPU/EYPU_Blue__PROv7.pdf]]. It is for primarily for workers but it is OPEN SOURCE so that if service users or other parties are interested, they are welcome to look and contribute their feedback too.
The following groups will find the manual most useful:
*Social workers
*Clinical psychologists
*Adult and child psychiatrists
*Family therapists
*Children and adolescent mental health service (CAMHS) workers
*Health and social care commissioners.
''Benefits of using the manual''
The manual will benefit your practice by:
*providing you with a detailed guide to setting up your own [[EYPU|Why we set up the EYPU]] that can be adapted to your own local circumstances.
*demonstrating how [[EYPU|Why we set up the EYPU]]'s approach to jointly managing cases with [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] results in more effective management and timely decision-making in relation to complex, high-risk families
*introducing you to [[mentalization-based practice|Mentalization-based practice]] and the difference that it can make to to families where parents are experiencing [[personality disorder/difficulties|Personality Disorder/Difficulties]].
!!!!''Welcome!'' This website is a little different to others.<br>[[Please take a moment to check out how it works|Navigate this website]]

The EYPU is based on joint working with other professionals from initial referral, through assessment and input by the EYPU into the Care Plan, and continuous liaison with the professional network, including Social Workers, Health Visitors, Adult Mental Health and GP’s, throughout the treatment process. This allows for clear and timely decision making in relation to risk, including emotional trauma/neglect and its developmental consequences. The ultimate aim for those families that complete the treatment programme is for the children to remain in the care of their parent/s, and to reduce substantially their use of statutory services, including crisis and emergency services.

We insisted upon referrals from social care and that there would be a continuing relationship with social care throughout treatment and that there would be no question of the handing over of cases to treat them and us handing them back, it was always going to be jointly managed because this is one of the big failings of services in relation to families because they are treated by disparate agencies which don’t properly work together in various ways.

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The material on this website is licensed to the Anna Freud Centre under a [[Creative Commons Licence.|http://creativecommons.org/licenses/by-nc-sa/3.0/]] You are free to copy and distribute the manual and free to adapt the manual to suit your needs. If you alter, transform, or build upon this manual, you may distribute your resulting work only under the same or similar license to [[this one|http://creativecommons.org/licenses/by-nc-sa/3.0/]]. You may not use this work for commercial purposes. You must attribute the material from this manual to the [[Anna Freud Centre|http://www.annafreud.org]] - but not in any way that suggests that the Anna Freud Centre endorses you or your use of this manual.
Permissions beyond the scope of this license may be available. Please [[contact the Anna Freud Centre|http://www.annafreud.org/pages/contact-us.html]] for more information.

This manual is authored by [[Minna Daum]], [[Nicola Labuschagne]] and [[Duncan Mclean]].
The material on this website is licensed to the [[Anna Freud Centre]] under a [[Creative Commons Licence|http://creativecommons.org/licenses/by-nc/4.0/]]. You are free to copy and distribute the manual and free to adapt the manual to suit your needs. If you alter, transform, or build upon this manual, you may distribute your resulting work only under the same or similar license to this one. You may not use this work for commercial purposes. You must attribute the material from this manual to the [[Anna Freud Centre]] - but not in any way that suggests that the [[Anna Freud Centre]] endorses you or your use of this manual.
Permissions beyond the scope of this license may be available. Please contact the [[Anna Freud Centre]] for more information.

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[[HOME|Introduction]] [[ABOUT US|About the EYPU]] [[SETTING UP AN EYPU|Setting up an EYPU]] [[SERVICE PRINCIPLES|EYPU Service Principles]] [[THERAPEUTIC INTERVENTIONS|Therapeutic interventions]] [[HELP|Help]]

Although EYPU staff take responsibility for assessing and communicating issues of risk to to the relevant agancies, a multi-family approach encourages all the parents to think about risky issues and how these may be thought about and managed on the unit. This helps parents to have a sense of agency around risk management which can be seen as a process in which they are actively involved.
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//Example: a mother discloses to the families that she is self-harming, drinking excessively, using cannabis, and bingeing and purging, in front of her three young children at home. She adds that she is finding it very difficult to manage her children, citing concerning examples of their out of control behaviour. Shocked and worried about her mental state, the families are nonetheless able to communicate their concerns about the risk to the children, urging the mother to utilise the help on offer if she is to stand a chance of keeping her children. When it becomes obvious that the mother does not feel able to use the help on offer from the EYPU, parents suggest a range of possibilites to keep both her and her children safe, including a hospital admission for the mother and temporary foster care for her children. This is significant feedback from parents who fear and resist any form of [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] involement. In addition, because this support and advice comes from her peers, the mother is able to engage in a risk management plan devised by her EYPU key worker and the children's social worker.//

[[Minna Daum]]
Senior Family Therapist
Co-manager, [[Specialist Assessment and Treatment Services]]
//Minna is the co-project lead of the [[Early Years Parenting Unit|About the EYPU]] and joint-author of the online manual.//
[[Duncan Mclean]]
Consultant Adult Psychiatrist
//Duncan is the co-project lead for the [[Early Years Parenting Unit|About the EYPU]] and joint author of the online manual//.
[[Nicola Labuschagne]]
Clinical manager
//Nicola is the Clinical manager for the [[Early Years Parenting Unit|About the EYPU]] and joint-author of the online manual.//
[[Lisa Bostock|http://www.socialcareresearch.com]]
Senior Research Fellow
//Lisa is an experienced social researcher, specialising in integrated working between health and social care. She helped design and review the online manual.//
<html><img src="https://dl.dropboxusercontent.com/u/198966407/%5Bimages%5D%20Anna%20Freud%20Centre/Team%20photos/claremein.jpg" align="left" style="width: 100px"/></a></html>''Clare Mein''
Clinical Psychologist
//Clare contributed to the design of the online manual.//
<html><img src="https://dl.dropboxusercontent.com/u/198966407/%5Bimages%5D%20Anna%20Freud%20Centre/Team%20photos/dickonbevington.jpg" align="left" style="width: 100px"/></a></html>''Dickon Bevington''
Child and Adolescent Psychiatrist
//Dickon is the creator of Anna Freud Centre's [[other online manuals|Online manuals at the Anna Freud Centre]]. He provided support and guidance in the startup of this new online manual.//

A meeting at the end of the day with all members of the [[therapeutic community|Therapeutic community]] provides both families and staff with an opportunity to reflect on how things have been.

Mentalization has been described as: The ability to understand the mental state of oneself and others which underlies overt behaviour. It is an imaginative mental activity that allows us to perceive and interpret human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, reasons). Bateman and Fonagy
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[[Mentalization and attachment]] are linked in that the capacity for mentalization is primarily developed within [[attachment]] relationships. It underlies the means by which individuals communicate and relate to each other. It also leads to the ability to recognise and manage feeling states within oneself.
[[Poor mentalization|Deficits in Mentalization]] leads to misunderstanding and fractures in relationships. This can result in insecure attachments and difficulties in [[Emotional Regulation]]. These are key features of [[personality disorder/difficulties|Personality Disorder/Difficulties]]. [[Good mentalization]] alows for the development of secure attachments and the ability to self-regulate feeling states with the help of others.
Mentalization can be assessed by considering [[Levels of Mentalization]]. Lower levels of mentalization will result in more rigid and inflexible behavioural responses, while higher levels will allow negotiated interactions with others. Everyone's capacity for mentalization will fluctuate depending on levels of arousal and the individual they are relating to.
Adults with [[personality disorder/difficulties|Personality Disorder/Difficulties]] can be thought of as having [[deficits in mentalization|Deficits in Mentalization]] that results in their inability to form stable cooperative relationships and impulsive/compulsive behaviour. this will impair their parenting ability and their being a secure attachment figure for their children.
Enhancing mentalization is the main focus of the EYPU. This is in both adults and their children so there will be better functioning parents and childrn who have good social/emotional development. The EYPU also aims to promote [[good mentalization|Good mentalization]] in the treatment, health and social care system around a family so that all relationships are negotiated in a flexible and open fashion.
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This tiddler is under development.
Mentalization-based practice (MBP) is linked to:
[[mentalization|Mentalization]]
[[mentalization-based therapy|Mentalization-based therapy]]
[[mentalization-based social work|Mentalization-based social work]].

Mentalization-based social work (MBSW) provides the theory and methods necessary to boost practitioner and agency confidence in decisions about risk and safety, especially in cases where anxiety is high and things have got ‘stuck’. It does this by providing:
*a clear and accessible developmental explanation of the origins and impact of risky behaviour that improves assessment and decision-making;
*an approach to direct practice that improves engagement with parents, children and adults from the start and helps them change risky behaviour.
Since [[mentalization|Mentalization]] describes the process through which one understands one’s own behaviours as shaped by one’s own mental states, it is closely allied to concepts such as emotional intelligence and reflective practice. Social workers need to have an understanding of their own value-base, emotions and responses to services users in order to practice reflectively rather than reactively.
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The concept of [[mentalization|Mentalization]] can provide a useful framework for thinking about:
1. How the service user experiences their world and their involvement with professionals;
2. How the emotional responses of professionals may impact on their ability to think clearly;
3. How the professional network around the service user may lose the capacity to think.
As a result it is a model of practice in child and family social work especially which promises to keep more children safely at home with their parents and to ensure the right decision is taken about permanent family life elsewhere, in those cases when the risk remains too high despite the enhanced intervention.
MBSW brings coherence and clarity also to assessment, decision-making and providing help effectively to children and parents. Rather than just describing risk and protective factors in order to weigh and measure them (with or without the use of standardised tools), it provides an explanation of how and why risk has developed in each case.

Mentalization Based Therapy (MBT) is an evidence based treatment for [[personality disorder/difficulties|Personality Disorder/Difficulties]] It is a collaborative therapy, which encourages parents and carers to identify and manage their frequently overwhelming emotions and relationship difficulties. The aim of the therapy is to improve the [[attachment]] relationship between parent and child, by helping parents to identify and manage their own emotional states and enabling them to be more aware of and responsive to their children's needs. This leads to a reduction in the frequency and intensity of contact with support services in the longer term.
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Type the text for 'Mentalizing system'

Senior Family Therapist
Co-manager, [[Complex Cases Court Assessment Service]], the Anna Freud Centre
Co-project lead, [[Early Years Parenting Unit|About the EYPU]], the Anna Freud Centre
Minna Daum is a UKCP Registered Systemic Psychotherapist who has worked in both the NHS and Third Sector. Part of her work over the last 25 years has consisted of carrying out and supervising multi-disciplinary court assessments and providing expert opinion on the risk of rehabilitation following neglect and abuse. For the last 10 years she has specialised in multi-disciplinary assessments of families involving parents with Personality Disorders/difficulties in public care proceedings. In 2011 she and Dr McLean set up the Early Years Parenting Unit in order to work therapeutically with parents with personality difficulties and their under-5 children on the edge of care.

Within [[therapeutic communities|Therapeutic community]], the purpose of a meeting at the start of the day is to bring everyone together to start planning their day and begin addressing any the concerns that they have.

The EYPU has adopted an open, multi-family treatment approach and can accommodate up to 10 families at different stages of treatment on the day unit any one time. New families coming into the EYPU are socialized into the day unit and to the EYPU system by 'older' families. This can help to facilitate the new families' involvement in the programme. Also, new families are able to see and hear about other families at various stages of treatment and this can foster a sense of hopefulness about the possibility of change. To this end, 'graduate' families play an important role in engaging new families during the [[assessment and engagement phase|Assessment and Engagement phase]].
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Multi-family group therapy involves working with a collection of families facing similar problems in a group setting. At the EYPU, all the families are known to [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]], their children are subject to [[Child in Need|http://protectingchildren.org.uk/cp-system/child-in-need/]] or [[Child Protection|http://protectingchildren.org.uk/cp-system/initial-assessment/child-protection-plan/]] plan or are on the [[edge of care|https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/330332/RR369_Assessing_parental_capacity_to_change_Final.pdf]]. In addition, parents have been identified as having [[personality disorder/difficulties|Personality Disorder/Difficulties]], which significantly impairs their capacity to regulate their emotions and to form enduring relationships.
Advantages of a multi-family approach:
[[Developing social networks]]
[[Empowering families]]
[[Families as 'consultants']]
[[Developing multiple perspectives]]
Multi-family activities can occur during [[parent-child work|Parent-child work]] including group games, swapping children, [[holiday programme|Holiday programme]], planning events together.

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Clinical manager and family therapist, [[Early Years Parenting Unit|02. Introducing the EYPU]]

It is important to recognize the different needs of older children on the programme and activites should be tailored to accommodate their ages and stages of development. In addition to participating in whole family and multi-family activities, it is important to help parents to try and find a way of spending some time on their own with their older children so that they also get the benefit of being attended to in an exclusive way by their parents. These interactions are videoed and discussed during [[video feedback|Video feedback]] sessions in the same way as during the formal treatment programme. Therapists or volunteers engage the other children in the family, either in individual play or in [[children's groups|Children's groups]].
Older children in the family who have not had the benefit of treatment at the EYPU or CAMHS can present with emotional and behavioural difficulties...

<<tiddler
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!We currently host four online therapy resources
[[Adolescent Mentalization-Based Integrative Treatment (AMBIT)|http://ambit.tiddlyspace.com]]
[[Mentalization-Based Therapy for Families (MBT-F)|http://mbtf.tiddlyspace.com]]
[[Parent Consultation Service (PCS)|http://pcs.tiddlyspace.com]]
[[Early Years Parenting Unit Manual|http://eypu-content.tiddlyspace.com/]]
!We are committed to sharing clinical knowledge
Our online therapy resources are created using [[tiddlyspace|http://tiddlyspace.com/]], a free web-hosting and information-sharing space. Tiddlyspace makes it easy to freely share knowledge and collaborate with others in our field. Other mental health organisations can pull the core content from this manual across into a new space, then build on it and adapt it to suit the needs of their particular clients and staff. For instance, there is currently [[a network of 53 local customised versions of the AMBIT manual|http://tiddlymanuals.tiddlyspace.com/#AMBIT]], based on the original Anna Freud Centre AMBIT manual.
We look forward to creating a similar network of [[EYPU|About the EYPU]] manuals, each sharing core content, but customised to fit the unique cultural settings and service demands of local EYPU practices. Please [[contact the Anna Freud Centre|http://www.annafreud.org/pages/contact-us.html]] for more information about starting a local [[EYPU|About the EYPU]] service and hosting a customised online manual based on this one.
''Our online manuals are intended as resources for trained health and social care professionals, and not as stand-alone learning tools. Please [[read our disclaimer|Disclaimer]].''

When parents are not participating in either individual or group therapy, they are required to work alongside therapists engaging in parent-child attachment based work. This is done through the medium of play, is videoed, and parents have the opportunity to reflect on these videos during [[video feedback|Video feedback]] in either [[individual therapy|Individual Therapy]] or [[parent-focused group therapy|Parent-focused group therapy]].
!!Parenting and attachment style
Parents with personality disturbances typically display insecure or disorganised attachment styles which are associated with lower parental sensitivity and insecure child–parent attachment relationships. Parents who are emotionally unstable, prone to mood disturbances (anxiety, depression), and who are unable to quickly regain a sense of calm and focus in the face of life stressors, typically find it enormously difficult to parent their children in consistent, emotionally attuned ways. This can lead to the development of insecure/disorganised attachment styles in children with poor socio-emotional outcomes. The overall aim of parent-child work is to enhance [[parental reflective functioning|Parental reflective functioning]] by promoting the parent's capacity to mentalize about the child and the parent-child interaction. This can start by simply helping a parent to be more emotionally attuned to her infant.
//Example: therapists noticed that a 4-month-old infant avoided eye contact to the extent that one of the therapists wondered whether the child had impaired vision. The mother confirmed that the child had no health difficulties. Careful observation of mother and infant revealed that the mother alternated between staring blankly into space in a pre-occupied way, and looming into her son's face in an intrusive manner, showering him with loud affection. When he cried, she responded by smiling, laughing or tickling him. Her son could only tolerate eye contact with his mother for a few seconds before appearing to shrink from contact with her and it appeared to therapists that his gaze aversion functioned as a means of reducing his levels of arousal. Therapists worked alongside the mother to help her develop a more emotionally attuned way of making contact with her baby. This involved helping the mother to notice that when her son averted his gaze, it might be a sign that he had had 'enough'. The mother was also helped to engage in simple, attachment based activities with her son (singing or talking quietly while looking at him, engaging in gentle, non-intrusive touch, and contingent mirroring). In a relatively short space of time, the little boy was able to seek out, hold and derive pleasure from eye contact with his mother and a range of people on the unit.//
The intensity of the parent-child relationship inevitably activates the parent's attachment system and if this system is insecure or disorganised, it is understandable that parents with personality problems might try to regulate their arousal by minimising the amount of time they spend playing with their children. On the unit, this can manifest in their pre-occupation with a range of distracting activities e.g. using their phones (messaging friends, checking social media sites) and prioritising their relationships with each other rather than their relationships with their children. Therapists need to find ways of alerting parents to this 'in the moment' and need to be prepared for hostile attacks when they do so. It is useful to use [[parent-focused group therapy|Parent-focused group therapy]] to discuss the importance of play and to get parents to think about ways of engaging their children in play. Parents can also be encouraged to come up with things they wish to do or work on with their children during the [[morning meeting|Morning meeting]] at the beginning of the day in order to focus their attention on the reason for their referral to the unit i.e. to improve their parenting in order to reduce the risks of emotional abuse and neglect.
The challenges inherent in the parent-child relationship are likely to be the main trigger of the attachment system, which may in turn compromise the parent's mentalizing capacities. It is not unusual to witness these parents teasing or mocking their children when they express fear, pain, or vulnerability. Although therapists need to understand this behaviour within the context of the parent's own insecure/disorganised attachment history, it is important to intervene quickly, drawing the parent's attention to the emotionally damaging aspect of their interaction with their child. Further work with the parent on ways of thinking about and managing their vulnerability in relationships can be addressed in individual and group therapy.
//Example: a year-old child, strapped in a high chair, reaches out for her mother who has just come back from spending an overly long time in the kitchen preparing lunch and talking to other parents. The mother responds by lavishing attention on another child directly opposite her daughter, saying to her 'Ooh, look R...look who I'm cuddling' in a provocative, mocking way. The mother appears to be oblivious to her daughter's initial cues of bewilderment then outright distress. When the mother continues with this behaviour, a therapist intervenes directly, telling her that she must stop because her daughter is very upset. The mother becomes angry with the therapist, telling her that she was only 'teasing' and that her daughter needs to 'get over it'//.
!!Mentalizing the child
Working alongside a parent and child engaged in play, the therapist focuses on what is happening in the moment, encouraging the parent to be curious about the child's states of mind and behaviours. Parents are invited to reflect on the child's nonverbal cues and to give a range of possibilites for their behaviour in an effort to increase [[parental reflective functioning|Parental reflective functioning]], i.e. to engage parents in thinking about their children in terms of their internal experience rather than just their behaviour. The therapist models [[good mentalization|Good mentalization]] by adopting a tentative stance of 'not-knowing' in relation to the child, taking care not be definitive. Parents have the opportunity to revisit these interactions via [[video feedback|Video feedback]] which provides a rich source for further reflection and a deepening of the attachment relationship.
Parents with personality problems can demonstrate impairments in their reflective functioning with associated [[deficits in mentalization|Deficits in Mentalization]]. It is not uncommon to hear the following:
//
*'He's trying to wind me up'
*'He doesn't want a cuddle, he wants a slap'
*'She's not upset, she's manipulating me'.
//
Promoting a mentalizing stance in parents with personality problems can enhance their abilities to envision the mind of their children, helping them to create a better understanding of their children, which is likely to improve the parent-child relationship and ultimately foster child development. In the above examples, the therapist might...
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In addition to one session of [[adult-focused group therapy|Adult-focused group therapy]] per week, parents will also engage in one session of parent-focused group therapy per week.
This mode of intervention is particularly demanding for parents with personality difficulties; in addition to the challenges already described in [[group therapy|Group therapy]], parents are also being asked to reflect on the minds of their children. Most parents find it challenging to have their parenting scrutinised and parents with personality difficulties who are exquisitely sensitive to criticism, shame and humiliation find it especially so. Add [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] involvement to the mix and parents can quite quickly lose their capacity to [[mentalize|Mentalization]] about their children by becoming defensive, withdrawing, retailiating against perceived criticism, and by sidetracking. Consequently, therapists running these groups need to work very hard to keep the group on track i.e. to engage parents in a way that helps them to be curious about their children's states of minds and the impact that they have on their children.
!![[Explicit mentalizing]]
It can be helpful to begin with [[explicit mentalizing|Explicit mentalizing]]. Because most parents with personality difficulties have experienced significantly disturbed parenting themselves, they can have distorted views of what their children ought to be able to manage or tolerate. Psycho-education can provide a safe place from which to start mentalizing around some of these issues by addressing a variety of subjects in the form of explicit themes. These can include:
*Parenthood; what it is like to be a parent; struggles and strengths in parenting
*Interplay of thoughts, feelings and behaviours; acknolwedging that even young children have thoughts, feelings and intentions
*Impact of parental mental states on children
*Child development
*Attachment
*The importance of play
*Boundaries and limit setting
*Separation/individuation
!!Mentalizing the child
As the parents start to feel a bit safer with each other and the therapists, they are more likely to feel able to join together to think about their children's states of minds and the impact that their own states of mind have on their children. Day-to-day incidents on the unit can be brought to the group for further thought and understanding. It is very important for therapists to model curiosity about what might be going on for children rather than falling back into the 'expert' role; not only is this counter to a mentalizing approach but can also give parents the message that there is a definitive answer as to what motivates a child's behaviour.
//Example: an infant in a high chair throws his spoon on the floor. His mother picks it up and he throws it on the floor again. His mother angrily tells the child off, saying 'He's doing this to wind me up'.
A child refuses to cooperate with an activity that her mother has taken some time to set up. The child runs off and quickly becomes absorbed in something else. The mother angrily tells a therapist that her daughter is doing this on purpose to make her look bad in front of staff who will tell [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] about her poor parenting.//

Parental reflective functioning (PRF) refers to a parent's capacity to reflect on their own and their child's internal mental experiences and to understand behaviour in the light of underlying mental states and intentions. Parents with high levels of PRF treat their children as if they were individuals with separate minds, which are not always immediately accessible to them. They demonstrate a willingness to be curious about their child's mental states, recognizing that they might get it 'wrong' in their effort to understand what might be going on for their child. [[Good mentalization]] and PRF go hand in hand and high levels of PRF predict attachment security, adaptive social-cognitive skills, affect regulation, and mentalizing capacities in children.
Parents with personality disorder are likely to have [[deficits in mentalization|Deficits in Mentalization]], which, in turn, impact on PRF. Impaired PRF is associated with deficits in emotional regulation, and disorganized attachment styles in children. This results in an increased risk of the intergenerational transmission of attachment disorders, problems in psychosocial functioning, and personality disorder. Consequently, one of the aims of treatment at the EYPU is to improve PRF in order to ensure better outcomes for children.

The term Personality Disorder can often cause considerable confusion as definitions are both broad and vague, so there is little clarity when the term is used. Definitions centre on an individual's difficulties in interpersonal relationships, social functioning, and identity.
It is rarely helpful to think in categorical terms, but rather to think of personality difficulties in terms of a dimension with parents considered in this manual as being relatively more dysfunctional than most.
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It is useful to consider personality functioning as having a number of domains; added to interpersonal relationships, social functioning, and identity, are affect recognition/regulation and psychiatric symptoms such as depression or anxiety. These domains are somewhat arbitrary but together will cover those areas of functioning that need to be comprehensively considered in the treatment of parents with personality difficulties. The domains are not exclusive, and the way a parent functions in a particular domain is interdependent with their functioning in the others. It is usual when a parent starts treatment to have only a very partial understanding of their personality functioining, and therefore during engagement an [[Assessment of personality functioning]] should be made.

Staff absences due to holiday leave and increased numbers means that the holiday programme will need to be a modified version of the normal treatment programme. For example, at the [[EYPU|02. Introducing the EYPU]], we have found that while it is important to offer parents a group therapy session, it has not been possible to have two therapists running the group because one therapist has needed to be available to work alongside volunteers in the [[children's groups|Children's groups]] while their parents are engaged in group therapy. Consequently, we have offered parents a shorter, hour-long group facilitated by one therapist. In order to accommodate individual therapy sessions, the holiday programme is shortened by an hour and parents are offered sessions at the end of the day. Volunteers stay behind to care for the children while their parents are in sessions.
While the structure and frequency of the holiday programme is decided by staff, an important part of [[multi-family work|Multi-family work]] is getting the families to collaborate with therapists in drawing up the holiday programme. Multi-family activities, events, and outings are put forward by the community and time is spent discussing the merits and logistics of each proposal. Therapists must be prepared to have cherished ideas dismissed or modified by the families; if families feel that activities, no matter how worthy, are foisted on them, they are unlikely to engage. Examples of multi-family activities in the holiday programme include:
*a trip to the seaside
*picnics in local parks
*visit to the Science museum
*visits to a local indoor play centre
*EYPU reunion day involving graduate families
*working with an art therapist on an agreed theme over the summer

The [[Specialist Assessment and Treatment Services]] assessed families where there would be:
*adult mental health problems, particularly personality difficulties
*parenting difficulties
*and worries about the development of the children.
Yet no service was comprehensive enough to address these concerns holistically.
Adult mental health services would show poor regard for the parent’s parenting capacity and demonstrate very little concern about the child’s development because they would see the parent separately from the children; equally, if the parents went to [[Child and Adolescent Mental Health services (CAMHS) |http://www.camh.org.uk]] services to get therapeutic help, CAMHS staff would say that their concern was about the child and the child’s development. They would be interested in the parent’s parenting in so far as it impacted upon the child but as far as the parent’s own emotional difficulties, they saw as not their province and felt particularly unskilled and unknowing about how to manage and deal with personality disorder’s in parent’s.
[[Setting up the EYPU|04. Setting up an EYPU]] was a result of what we saw as an poverty of an integrated response to the families in terms of the difficulties that they were facing. It was not just integrating the [[treatment|Therapeutic interventions]] of the different aspects of the families, parents, parenting and child but is also about integrating the approach by professionals so the system around the families was [[integrated]].

Once an 'owner' or 'champion' for the [[EYPU|About the EYPU]] has been identified in [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] (CSC), s/he can advise on and support the best strategy for publicising it. An early meeting should be held with senior managers across Children's Services, followed by meetings with locality teams and specialist teams such as looked after children teams. In each case project leads should ask for 20 - 30 minutes to be set aside during a regular team meeting.
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In presenting the work of the EYPU, in addition to describing the day unit and its approach, exclusion criteria and so on, emphasis needs to be placed on the following:
*the day unit is focused on parents with [[personality disorder/difficulties|Personality Disorder/Difficulties]] and their under-5 children on the edge of care;
*parents do //not// need a diagnosis of [[personality disorder|Personality Disorder/Difficulties]] to be referred to the EYPU;
*the EYPU day unit is at the centre of a whole service offering [[consultations|Consultations for social workers]] and [[training |Training for Social Workers]] for social workers on working with complex families, and for those cases not referred to the EYPU, therapists will offer consultation to networks (Social Workers and Health professionals) to help them think about and manage these cases.
Social Workers may well be suspicious of a service that claims to work alongside them, sharing risk, management and decision making in complex cases; the real work of establishing relationships needs to be done via joint working with families.

It is possible to adjust the layout of the website, but we recommend only try to do this if you are confident with CSS and HTML code.
!!!!![[Learn more about CSS|http://www.w3schools.com/css/default.asp]]
If you do want to make changes.... We suggest you create your own brand new blank stylesheet, and selectively add the code for any elements from the existing stylesheets that you want to override. This is a good way of keeping track of any customisations you've made to the original layout.
In CSS (cascading style sheets, which tiddlyspace operates on) the style sheets are linked in a 'cascading' chain. Any sheet that comes later 'overrides' the sheets that come earlier. So to make changes to the existing layout, you will need to put your new, blank Style sheet at the end of the chain, Do NOT delete or change the existing stylesheets.
This is the hierarchy:
|[[StyleSheetColors]]|Tiddlyspace default, DO NOT edit|
|[[StyleSheetLayout]]|Tiddlyspace default, DO NOT edit|
|[[StyleSheet]]|Tiddlyspace default, DO NOT edit|
|[[StyleSheetTiddlySpace]]|Tiddlyspace default, DO NOT edit|
|[[StyleSheetTiddler]]|Tiddlyspace default, DO NOT edit|
|[[StyleSheetAFC]]|Customisations to the Tiddlyspace default by the Anna Freud Centre, DO NOT edit|
|[[StyleSheetCustom]]|Add your customisations here only. This sheet is left blank for you. Any code you enter here will override code in the above sheets|

!Principles
The EYPU team will work with a number of complex families, and in addition to working on the day unit the team will be involved in liaising with professionals, home visiting, attending court, joint work with statutory professionals, and so on. The most important principle in recruiting a staff team is to establish and maintain a team able to think together and support each other in work that can often be overwhelming and challenging.
!Nuts and bolts
The team consists of a clinical manager (Band 8) and three therapists (Band 7). Each is employed for three days per week, to cover two non-consecutive multi-family day unit days, and one intervening day for liaison, home visiting, etc.
!Characteristics of the team
//Skill mix//: while we contend (see below) that the most important factors to take into account are personal qualities, it is useful to have a skill mix to cover the various aspects of clinical work, particularly adult-focused and child- or family-focused intervention.
//Gender mix//: equally, it is helpful to have both men and women on the team.
!Personal qualities of staff
Working with parents with personality difficulties is highly demanding at an emotional level. They can be highly controlling, hostile, aggressive and bullying. Therapists need to be sufficiently robust to manage their own vulnerable feelings without becoming overwhelmed and withdrawing as a result. They need to be able to think on their feet in the face of very challenging behaviour. They need to function well in groups. They need to have a sense of their own authority as therapists.
!Recruitment process
The qualities set out above need to be reflected in the Person Specification, and candidates shortlisted accordingly.
The process of interviewing needs to be sufficiently demanding to test the qualities of the candidates. We therefore recommend that a 'longlist' is created, and a group interview conducted as part of the shortlisting process. The interview panel should include a service user who is a parent. The question put to the group by the panel, who can facilitate the discussion, is 'what are the challenges of working with a group of parents with personality difficulties and their under-5 children?'
Once the unit is up and running and families are engaged in treatment, the families should be included in any further recruitment that might need to take place e.g. if a member of staff decides to leave. In this case, the 'longlist' group interview will be conducted by the families on the day unit with the therapists in attendance. The parents will need to come up with interview questions and will be responsible for drawing up a shortlist of candidates to proceed to further individual interviews. Practically, it is a good idea to hold two 'longlist' groups so that candidates have enough time to give an account of themselves and parents feel that they have sufficient time to make a judgement. There should be enough time between interview groups for therapist facilitated discussions about the candidates to ensure that each candidate is given a fair hearing.
At the EYPU, parents have asked candidates two questions; one to be answered individually and one to be discussed as a group:
1. //Tell us a bit about yourself and why you think this role is right for you?
2. What would you do if a parent started shouting and getting angry in front of the children and threatened to leave the unit? Discuss.//
Candidates who are shortlisted will be interviewed by a panel comprising EYPU staff as well as a service user who is also a [[graduate|Graduate groups]] of the EYPU [[programme|Therapeutic interventions]].
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This tiddler is under development.

Every six weeks, therapists meet with the parents in a reflective group. In order to facilitate discussion on progress, the therapists provide [[video feedback|Video feedback]] about how they think each family is doing which is watched with the parents as a group.

Risk Management is a central concern of an [[EYPU|About the EYPU]] and is of the highest priority as a therapeutic aim. It is essential that concerns about the safety of family members remains of joint concern between the therapeutic unit and other professionals, especially [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]] , who have responsibility to ensure children's safety.
One of the reasons for families attending the unit will be because there have been concerns about a child's parenting such that the chld or children have been physically, sexually, emotionally abused and/or neglected. As the carer(s) have personality difficulties they may also be at risk of various forms of self harm, including substance abuse. These latter risks will usually also be a risk to the child(ren).
The concerns about harm to either children and/or adults should be made explicit at the start of the engagement process so that is clear to carers that the therapeutic unit shares these concerns with social care and other professionals. Carers must know that the therapeuyic team will always inform others such as social care of any concerns they have about harm to family members.
[[Assessing risk]] is a continuous process whilst families are attending the unit, though formal recording will be necessary whenever there is new information or a significant change in risk.

Therapists need to develop the confidence to address damaging and destructive behaviour 'in the moment'. It takes a certain amount of skill to do this in a straightforward, non-confrontational way with parents but it is essential that therapists find a way to do this so that they do not become complicit in allowing damaging parenting to continue. Setting limits and having clear consequences for serious boundary transgressions promotes the possibility in people's minds of a straightforward, clear, and uncorruptible benign authority. With the support and, at times, intervention of managers, therapists and families should feel confident that outside authorities, like the police, will be summoned in the event of criminal acts, like threats of physical harm or death. Close team working, support and supervision can help therapists to develop their sense of authority when working with complex families.
//Example: a mother starts shouting and swearing at her 4-year-old, accusing her daughter of trying to make her look bad so that social care will remove her. Although staff are aware that the mother has come into the unit in a state of anxiety because she has overslept and is fearful of being 'reported' to Social Care, the most pressing issue to address is the damaging way in which she is engaging with her child. One therapist takes her aside and tells her that she needs to go to another room while another therapist attends to the child. The mother is highly resistant to this plan, insisting that she wants to leave the unit with her child. The therapist dealing with the mother lets her know that this cannot happen because her high levels of anger and distress are damaging to the child. The therapist is able to help the mother to calm down and the mother is told that her behaviour was damaging to her child and that this can not continue. The mother is then able to talk about her high levels of anxiety prior to attending the day unit and the therapist advises her to discuss this in her individual session with her key worker. Mother and child are re-united. The mother is aware that this issue will be discussed with Social Care.//

In [[setting up an EYPU|About the EYPU]], the principle that all elements of the service should be [[integrated|Integration]] needs to be considered, and in particular how the service will relate to the aims and requirements of other agencies, particularly [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]].
To achieve this, joint working, liaison, [[consultation|Consultations for social workers]] and [[training|Training for Social Workers]] are central to the business of the EYPU as direct work with families. The value of the [[EYPU|About the EYPU]] needs to be evaluated not only in terms of outcomes for families who successfully complete the EYPU [[day programme|Day programme]], but also in terms of effective management and timely decision-making in relation to complex, high-risk families. Underlying this, the aim is to increase social workers' sense of confidence and competence and support their development of [[mentalization-based social work|Mentalization-based social work]].

In order to be effective, any service catering for complex families must be based on the following set of principles. All aspects of the structure of the service or [[Service Organisation]] will need to reflect these principles.
[[Integration]]
Professional networks around people with personality difficulties are typified by fragmentation, confusion of roles, disagreements between professionals on the nature of the concerns and how to address them, and often open or covert conflicts. This leads to paralysis in professional networks and delays in decision making, while interventions are piecemeal and ineffective. In particular, and especially in cases involving risk to children, there is an unhelpful separation between the professional holding statutory authority (the child's Social Worker) and other professionals.
A basic principle of the EYPU is to combat this fragmented approach to complex families and to adopt instead a wholly integrated approach in which there is no separation between the clinical service offered to the family and statutory authority held by Children's Social Care and other agencies such as Health.
[[Comprehensiveness]]
There is universal agreement among professionals working with complex cases/personality disorders that in order to be effective, clinical services must be comprehensive, that is they must address all the problems that the family or individual presents.
[[Mentalization]]
Mentalization is thought of as the basic means by which individuals communicate effectively with each other. All relationships in the service, that is, between professionals and the family, the parents and their children, and professional relationships within and between agencies, need to work towards a [[good mentalizing]] stance.
[[Co-created services]]
[[good mentalizing]] always implies a co-operative relationship between individuals and agencies. It is therefore important that from the beginning and in a continuing manner the ways in which the service functions is decided together with all those involved, including both the client families and other agencies.
[[Authority]]
The question of authority is central to any service treating complex families, in the sense that everyone is subject to both legal and social boundaries to their behaviour, and the treating staff must negotiate how transgressions of these boundaries are to be addressed. This is a particularly difficult issue in a service where parents have transgressed acceptable boundaries to behaviour in relation to both children and others in many respects.
[[Risk]]
Managing and minimising risk is a primary objective of the service. With the involvement of children there is a priority in preventing physical or emotional harm by trauma or neglect. In the EYPU service there are also the frequent risks to the physical and mental health of the parents involved, which also need to be actively considered.

For this website, you can choose many pages are displayed at once
You can either:
(a) [[see one page at a time|#SPM:true]] as you click around the website. This is the setting we recommend for most users, because it allows you to use this manual like an ordinary website. Especially recommended for those new to Tiddlyspace.
(b) [[collect all the pages |#SPM:false]] you read and have them all accumulate on your screen as you click around the manual. We'd recommend this mode only for 'old-school' Tiddlyspacers those who particularly like this note-hoarding setup. New users may find it a little unweildy or confusing. It takes a little getting used to, but some people prefer it.

Success of the [[EYPU|About the EYPU]] is dependent on [[integration|Integration]] with [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]]. This means that from the start, effort must be made to join the existing child welfare system with the explicit intention of working in an [[integrated|Integration]] way with statutory agencies, specifically [[Children's social care|http://www.scie.org.uk/publications/introductionto/childrenssocialcare/]]. Crucially, this encourages both a genuine sharing of [[risk|Assessing risk]] between statutory agencies and the [[EYPU|About the EYPU]] and that continual efforts are made to address potential splits between agencies.
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As with all aspects of the programme, the aim is to maintain a [[good mentalizing|Good mentalization]] stance and to work towards creating and maintaining a [[mentalizing system|Mentalizing system]].
Setting up an EYPU requires the following steps:
[[Identifying funding]]
[[Establishing relationships with partner agencies|Establishing relationships]]
[[Choosing premises]]
[[Recruiting staff]]
[[Publicising the EYPU]]

!Choose a reading mode
*[[Single-page viewing mode |#SPM:true]] (will open a new session in a new tab)
*[[Page-collecting mode |#SPM:false]] (will open a new session in a new tab)
[[Find out more about these different modes|How to navigate this website]]
!How to
<<list filter "[tag[Help]]">>
<<list filter "[tag[Site admin]]">>
*[[info]]
''Not on this list?''
<<newTiddler "How to..."
label:"add a new 'how-to' item"
text:"So here's how you do this nifty thing in tiddlyspace, right...."
tag:[[Site admin]]>>Figured out how to do something great in tiddlyspace? Share the power!
or... [[post a question on the tiddlyspace forum|https://groups.google.com/forum/?hl=en-GB#!forum/tiddlyspace]]
!Look under the hood
Here are some other bits and bobs you'll find handy, once you get the hang of Tiddlyspace:
''Recent'' shows which tiddlers have been added or edited recently.
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''Orphans'' are Tiddlers that aren't linked to any other tiddlers yet.
''Missing'' are Tiddlers you've mentioned in text somewhere, but haven't got around to creating yet.
''Shadows'' are tiddlers that don't contain PCS manual content, but just sit 'behind the scenes' and define the layout/structure/functioning of the website. (We strongly recommend you don't try to edit these, unless you are confident with CSS and HTML code).
<<tiddler Backstage##Tiddlers>>

!Upload an icon
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If you haven't already done so, you should provide a brief decscription of yourself and what you're using this space for. To do this, just edit the [[SiteInfo]] tiddler (keeping the title the same of course).
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!Change the default tiddlers
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!More Advanced customisations
If you know HTML and CSS, you can edit some or all of the following tiddlers to customise your space further:
* PageTemplate
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The [[Anna Freud Centre]] provides specialist services undertaking comprehensive assessments of children and families in public and private family law proceedings nationwide. Our expert witness assessments also cover viability assessments.
We are dedicated to serving the most disadvantaged children in society. Our approach is based on systemic, psychodynamic principles with a strong emphasis on attachment-focused assessments to serve the best interests of the child.
''The Team''
The team combines highly acclaimed specialist services from the Anna Freud Centre and former senior staff from the Marlborough Family Service, comprising a range of multi-discipline workers including Child & Adolescent Psychiatry, Adult Psychiatry, Clinical Psychology, Family Therapy, Child & Adolescent Psychotherapy, Play Therapy and Social Work.
The team has expertise in assessing the following issues:
*Psychiatric, psychological and cognitive profiles of parents and children
*Parenting capacity
*Entrenched parental contact, residence disputes and placement needs
*Parental mental health and its impact on parenting with a particular specialism in:
o Personality Disorder
o Postnatal Depression
o Post-traumatic Stress Disorder
o Eating Disorders
o Factitious/Fabricated Illness Disorder
Childhood adversity:
o Child abuse and neglect
o Exposure to domestic violence
*Children’s therapeutic and placement needs, including adoptive/foster placement breakdown
*Attachment and bonding
We are also able to offer subsequent therapeutic work for children, adults, parental couples and families, as well as multi-family group work.
The team has specific experience of working with different cultural groups and interpreters, thus able to undertake culturally sensitive work to families from a wide range of ethnic backgrounds.
''The Assessments''
Our assessments often begin with a meeting involving the network, i.e. parents in the family and professionals, during which the assessment process is outlined and the concerns about the family are explored.
We help family members understand the assessment process and ensure they have the opportunity to ask questions and air their views during the process.
Family members are seen individually and together, both at the Anna Freud Centre and in the community (home, school and other relevant settings).
Intensity and scope of the assessments depend on the specifics of each case.
Team members write a comprehensive report upon completion and are usually invited to attend court for cross-examination at the final hearing.
Further information about the service can be found here [[http://www.annafreud.org/pages/sats.html]]

Because holidays can be stressful for all parents and especially so for parents with limited internal and external recources, the [[EYPU|02. Introducing the EYPU]] closes for only one week during the school summer holidays and for two weeks during the Christmas break. Christmas can be a very difficult time for these parents if they have fractured relationships with extended family members so the [[EYPU|02. Introducing the EYPU]] offers families the option of 'dropping in' for one day over the Christmas period. Consequently, in order to ensure that the day unit is adequately staffed, it is important for therapists to organise their holiday leave in such a way as to ensure that at least two therapists are working on the day unit at any one time over holiday periods. Volunteer staff are particularly helpful during the holidays when there are increased numbers of children on the day unit.

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All parents and their child(ren) under five years of age attend the [[EYPU|About the EYPU]] on a Monday and a Wednesday, from 09:30 to 15:00. On Tuesdays, the team focus on consultation, professional meetings and home visits. When designing the [[day programme|Day programme]], it may be useful to consider the following structure and frequency:
*A two day programme whereby families attend the Unit between 9.30 – 15.00 to enable sufficient time for treatment to take place as well as allowing staff time at the end of direct work with families to write notes and debrief
*Type and number of therapy sessions offered to families via the [[day programme|Day programme]]
*A day in the middle for staff to have other activities, including [[supervision|Supervision]], [[reflective functioning group|Reflective functioning group]], training and time to do liaison when not actually working directly with the families
*[[Start|Morning meeting]] and [[end|Meeting at end of the day]] each day with a group meeting.
It is worth noting that ordering taxi's for all families can ensure attendance at the Unit.
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Families in which a parent or parents have personality difficulties arouse very strong feelings in those attempting to help them. Added to this, the threat of risk to either their children or themselves is ever-present. These two factors together can give rise to feelings of helplessness in workers that there is little they can do to change the situation, and this leads to a variety of unhelpful responses, including for example becoming over-controlling, giving up and ignoring the problem, placating a bullying stance, adopting a simplistic solution, and so on. In a team, whether in social care or a therapeutic team, members will inevitably take up one or other of the more unhelpful responses, and if these responses are contradictory team members will be in conflict with each other. They will lose their capacity to think and will require supervision to regain this capacity and to form a mentalizing structure to help the family.
The aims of supervision are to:
*Create and maintain staff cohesiveness
*Help staff maintain their professional role in relation to families
*Develop flexible strategies for engaging families and promoting change
*Reconcile different perspectives staff may have on families
*Help staff develop a focus for mentalizing within each of the different [[therapeutic community|Therapeutic community]] settings, including [[individual therapy|Individual Therapy]], [[group therapy|Group therapy]], [[parent-focused group therapy|Parent-focused group therapy]] and [[parent-child work|Parent-child work]].
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//Example
A family is referred that the therapeutic team cannot understand why the children have not already been taken into care. How is this then managed?//
Contexts for supervision
*Consultations
*Liaison with CSC and other professionals
*Reviews with families/CSC
*Individual
*Group
*Reflective group
*Peer supervision in the [[therapeutic community|Therapeutic community]].

Court proceedings can be viewed as evidence of systematic failure to grasp the difficulties that there are in families with [[personality disorder/difficulties|personality disorder/difficulties]]: there are two failures:
*[[systemic neglect|Systemic neglect]] which is failure to think about parent’s difficulty in engaging in attachment terms but rather to simply to react to it by referring families from one service to another so producing a systemic disintegration.
*[[Loss of authority|authority]] in the system whereby professionals would deny the level of child protection concerns in order to maintain a relationship with the family.

Systematic neglect is an aspect of hopelessness that professionals feel when they are trying to engage families with [[personality disorder/difficulties|Personality disorder/difficulties]]. It is also a response to an anxiety about child protection. There is a turning away on behalf of the professionals who have to come into contact with such families which leads to a paralysis in a [[non-mentalizing system|mentalization]] resulting in delay about making decisions about cases.

<<timeline filter:"[tag[Team notes]]">>

!Team notes
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!Manual development
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Do you have an idea for how to improve this online manual? Jot it down for future development! <<newTiddler "New idea"
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tag:[[Manual development]]>>
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{{credits{
image by: [[Highways Agency|http://www.flickr.com/photos/highwaysagency/9410622712/]]
}}}

Mentalizing in psychotherapy is a process of joint attention in which the parent's mental states are the object of scrutiny. The therapist is continually constructing and reconstructing an image of the parent in their mind which is shared with the parent in an effort to help the parent understand what they feel and why they experience what they do. Thus, the aim of therapy is to enhance the [[parent's capacity for reflective functioning|Parental reflective functioning]].
!!Therapist stance
The therapist's stance is characterised by curiousity and 'not-knowing'. 'Not-knowing' is not the same as having no knowledge; it is a reflection of the sense of mental states being opaque and that the therapist can not have any more idea of what is going on in the parent's mind than the parent themself. The therapist needs to be able to tolerate, verbalise and explore different perspectives with no assumption that their persepective should hold sway.
The therapist's primary concern should be the parent's state of mind, not their behaviour; what is happening in the parent's mind 'now' that has created the current situation as well as underlying problems. The therapist demonstrates their willingness to find this out with active questioning.
//
*Why do you think that he said that?
*Perhaps you felt I was judging you?
*What did you make of her behaviour?
*Why do you think she did that to you?
*What do you make of what has happened?
//
It should be acknowledged that the therapist is constantly at risk of [[losing the capacity to mentalize|The therapist's mentalization failures]] in the face of a non-mentalizing parent and this simply has to be owned up to.

The therapist is constantly at risk of losing the capacity to mentalize in the face of a non-mentalizing parent and this simply has to be owned up to. As with other instances of breaks in mentalizing, such incidents require that the process is 'rewound' and the incident explored. Hence, in this collaborative parent-therapist relationship, both have a joint responsibility to understand mental processes underpinning events both within and outside therapy sessions.
//Example://
!!Mentalizing the transference
Rather than interpreting the transference, the therapist should attempt to mentalize the transference i.e. encourage the parent to think about the relationship they are in at that moment with the therapist with the aim of focusing their attention on another mind, the mind of a therapist. The aim is to assist the parent in the task of contrasting their own perception of themselves with how they are perceived by another. The following example refers to the session described above:
//Example:
In her next session with the parent, the therapist acknowledges how she lost her capacity to think in the face of perceived intimidation, inviting the parent to rewind and explore the events leading up to her leaving the unit. Initially denying that she had been intimidating, the parent is able to acknowledge the therapist's experience of her, is able to talk about the thoughts preceding her actions, and agrees that her behaviour might have lead to the therapist feeling intimidated. In this way, the parent's attention is focused on the therapist's mind and provides her with contrasting information about the way in which she perceives herself and how others, including the therapist, perceive her.//
!!Mentalizing versus insight
Whilst the therapist might point to similarities in patterns of relationships in the therapy and in childhood or outside of the therapy, the aim is not to provide the patients with an explanation (insight) in order to control their behaviour. Rather, the goal is to highlight a puzzling phenomenon that requires thought and contemplation. In the example given above, the parent was subsequently able to talk about her pattern of resorting to intimidation and threats when she felt cornered. Parent and therapist could start to think about this phenomenon and explore alternative strategies for manoeuvering oneself out of a corner.

All material relating to WHY we work in the way that we do is tagged with this.

Therapeutic interventions are delivered via the [[EYPU|About the EYPU]]'s [[day programme|Day programme]]. Most families will work with the EYPU team for up to 18 months. Right from the referral stage parents/carers are involved in planning their treatment and this will continue through completion of the programme. When thinking about developing an [[early years parenting programme|http://www.annafreud.org/data/files/EYPU/EYPU_Blue__PROv7.pdf]], the following elements are essential:
*The way in which the overall [[service is organised|Service Organisation]]
*The [[structure and frequency|Structure and frequency of the day programme]] of the day programme
*[[Mentalization-based treatment|Mentalization-based therapy]] for families delivered via the [[day programme|Day programme]].
[[EYPU service principles|EYPU Service Principles]] apply to all aspects of [[service organisation|Service Organisation]] and [[treatment|Day programme]].

[[Therapeutic Communities|http://www.therapeuticcommunities.org/what-is-a-tc/]] are structured, psychologically informed environments. They are places where the structure of the day, different activities and social relationships are all deliberately designed to help improve people’s health and well-being.
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The therapeutic community should always aim to be a good [[mentalizing system|Mentalizing system]]. Staff and families will need to work cooperatively within the clear structure and boundaries of the [[day programme|Day programme]] in order to ensure that the therapeutic community operates in a reflective way.
Creating a mentalizing therapeutic community requires staff and families to identify areas of concern or areas of the community's functioning in need of modification in a [[collaborative way|A collaborative approach]]. The whole community then needs to think about potential solutions which might work, which can be trialled and, if necessary, re-modified.
Every six weeks, parents and therapists meet as a [[group to reflect on their progress|Reflective group]].

Therapeutic interventions are delivered via the [[EYPU|About the EYPU]]'s [[day programme|Day programme]]. Most families will work with the EYPU team for up to 18 months. Right from the referral stage parents/carers are involved in planning their treatment and this will continue through completion of the programme.
The [[structure and frequency|Structure and frequency of the day programme]] of the day programme will be decided by the managers of the project, initially in consultation with the staff, but with the continuing possibility of modifying the programme together with all participants including the families themselves.
Important elements of the therapeutic day programme will include:
[[Multi-family work]]
[[Therapeutic community]]
[[Individual Therapy]] for parents
[[Group therapy]] for parents
*[[Adult-focused group therapy]]
*[[Parent-focused group therapy]]
[[Parent-child work]], including [[video feedback|Video feedback]]
[[Children's groups]]
[[Holiday programme]] to include [[older children in the family|Older children]]
[[Graduate groups]]
[[Delivering the day programme]] is dependent on a staff team with a range of therapeutic expertise and personal qualities that enable them to offer a range of therapeutic inputs over the course of a day.
[[EYPU service principles|EYPU Service Principles]] apply to all aspects of [[service organisation|Service Organisation]] and [[treatment|Day programme]].
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To be reorganised....
When thinking about developing an [[early years parenting programme|http://www.annafreud.org/data/files/EYPU/EYPU_Blue__PROv7.pdf]], the following elements are essential:
*The way in which the overall [[service is organised|Service Organisation]]
*The [[structure and frequency|Structure and frequency of the day programme]] of the day programme
*[[Mentalization-based treatment|Mentalization-based therapy]] for families delivered via the [[day programme|Day programme]].
[[Risk management|Risk Management]] is a central concern of the [[EYPU|About the EYPU]].

All therapies can be conceptualised as attempts to increase capacity to mentalize, though most therapies will privilege one aspect of mentalizing over others.
Cognitive behaviour therapy enhances mentalizing in relation to cognitions. It also adds structure, focus and a hierarchy of priorities in relation to a therapeutic process. Some difficulties it might have with complex cases are that it tends to privilege cognitions over feeling states, and in particular can ignore deficits in the capacity to mentalize.
Systemic therapies can enhance awareness of mentalizing processes in a number of ways. Perspective-taking is an inherent part of systemic therapy, recognising the error-prone nature of imagining another person's perspective. Systemic therapy also by its nature demands of participants that they imagine the mental states of others. Its difficulties with complex cases can be that its focus is interpersonal, while an individual may be preoccupied by his/her subjective state.
Psychodynamic therapy can enhance mentalization by self-reflection, and can extend the mentalizing process to possible unconscious factors. Its focus is particularly on an individual's subjective state. In complex cases where an individual has personality difficulties this therapy can cause a number of difficulties. Interpretations can be felt as highly intrusive and judgemental, rather than an exploratory, imaginative process. Breakdowns in communication with poor mentalizers regularly occur.

Social work teams have the opportunity to attend a training session to develop thinking about parents with [[personality disorder/difficulties|Personality Disorder/Difficulties]] and the impact this has on their children's development. This looks at how to deal with parents with personality disorder/difficulties, examining such issues as parental sensitivity to criticism, and parents who lie. As well as providing an explanation of personality disorder/difficulties and its effects on families and relationships, training explores practical advice on dealing with personality disorder/difficulties parents in a professional setting, such as how to deal with angry, confrontational meetings and attacks on the professional's competence and integrity, and assessing children's attachments to parents with personality disorder/difficulties.
The [[Anna Freud Centre]] offers a [[two day workshop|http://www.annafreud.org/courses.php/17/personality-disorder-parenting]] on how personality disorder relates to parenting and its impact on children's development. This course is suitable for CAMHS clinicians, social workers and adult mental health professionals who have an interest in working with parents with personality disorder.

!What if...
<<list filter "[tag[Troubleshooting]]">>
<<newTiddler "A curly situtation"
label:"add a troubleshooting advice item"
text:"How to address this issue in our treatment model..."
tag:[[Troubleshooting]]>>
Think there's something missing from this list? Contribute to the manual by writing about an complex or unusual situations you've dealt with.
This is the space to reflect on times when things haven't quite gone to plan, or something unexpected has come up that has required your clinical judgement or called on knowledge or skills that are not already covered in this manual.

Video feedback has become an increasingly common therapeutic intervention in parent-child psychotherapy. The powerful experience of watching themselves and their children interact on video helps parents to become more sensitive to their children’s communicative attempts and helps them to develop more attuned ways of responding. Because the visual material speaks for itself, it engages parents immediately in the process of reflecting on their emotional interactions with their children. This process can feel safer because reflection occurs at a distance, in that it is not happening 'right now'. Video feedback is an important tool in enhancing [[parental reflective functioning|Parental reflective functioning]] because it encourages parents to reflect on their own mental states and those of their children from a third person perspective.
Video feedback interventions are based on free-play interactions between the parent and the child. The videos should be taken in such a way as to tightly frame the parent and child so that facial expressions are shown on a relatively large scale. This allows the parent and the therapist to focus on the emotional interactions between the parent-child couple when they watch the video together.
The parent and the therapist try to identify together exactly when and how and in what sequence the child smiles, averts their gaze, frowns, ignores them, walks away, or becomes distressed. This raises parental awareness of the child's ability to give and respond to sometimes minute, but nevertheless identifiable cues. Taking care to admire the parent-child couple whenever possible, the therapist encourages the parent to comment on moments of attunement as well as on derailments, or noncontingent behaviour. The focus should always be on the mental state of the child and the parent, and particularly on reflecting together, about what is happening in the parent-child interaction in the moment.
Toward the end of this short video, Martin one of the parents speaks eloquently about the experience of being videoed.
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//Example: a mother and a therapist are watching a piece of footage of the mother and her 12-month-old son playing a simple game involving passing a toy back and forth between each other. The mother and the therapist comment on the little boy's facial expressions of enjoyment (smiling, gurgling, laughing) and her contingent expressions of delight. The therapist comments on how engaged the child appears to be with his mother and how good they look together.
In the video, the mother then turns away from the child to join in a conversation that two other parents are having behind her. The therapist draws the mother's attention to her son's reaction. The mother notices that her son stops smiling, then frowns, then reaches across the high chair to try and touch her hand. When his mother does not turn around, the child waves its arms in the air, kicks out, and starts to make fretting noises. Eventually, the mother turns back to her child. The child continues to be fretful and refuses to engage further in the game. The mother takes the child out of the high chair and cuddles him. The child calms down, strokes his mother's face, and, after a few minutes, starts to smile at her.
The mother is astounded to see the impact that turning away has had on her child, commenting 'Look at that...there I am yapping away and I'm not paying him any attention...'. Therapist and parent comment on the impact of the mother's mental state at the time (preoccupied) on the child's possible mental state (confused, anxious, abandoned, angry). The therapist is also careful to comment on how the mother managed to repair the situation by re-engaging with the child in an attuned way, commenting on how much happier the little boy appears to be when she does so//

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!!!!''Welcome!'' This website is a little different to others.<br>[[Please take a moment to check out how it works|Navigate this website]]

Welcome to team notes. This is a space to keep a record of your brainstorming about clinical ideas, service development, research.... Use it to keep your meeting minutes, or anything else you might want to look back on as a team.

<<tiddler
box1 with: what
>> {{below{
!Heading
Our service supports parents or carers who....
!Heading
More about the intervention...
!A mentalization-based approach
We take a mentalization-based approach. Mentalizing means holding an attitude of trying to understand people’s behaviour and decisions by considering what might be happening ‘on the inside’ (their feelings, thoughts, desires, beliefs, intentions). We can think about mentalizing as ‘keeping minds in mind’. During a PCS phonecall, the parent and therapist try to make sense of what is happening for child and the family by wondering together about the mental states that lead up to a problem.
!!!!![[Find out more about mentalizing|What is mentalizing]]
!A collaboration between parent and professional
Shared decision making definition
!We are not an emergency or crisis service
For urgent psychological assistance or medical advice, contact [[your local GP|http://www.nhs.uk/Service-Search/GP/LocationSearch/4]] or the A&E department at [[your nearest hospital.|http://www.nhs.uk/Service-Search/Accident-and-emergency-services/LocationSearch/428]]
If you have concerns about the safety or well-being of a child or young person contact the Children's Services Department of [[your local council|https://www.gov.uk/find-your-local-council]] or call the [[NSPCC|http://www.nspcc.org.uk/]] on 0808 800 5000.
{{credits{
image credit: 1. [[Owen Lin|http://www.flickr.com/photos/owen-pics/6027687993/]]
}}}

<<tiddler
box1 with: whatismentalizing
>> {{below{
!Mentalizing is about making sense of behaviour in terms of mental states
Mentalizing means holding an attitude of trying to understand people’s behaviour and decisions by considering what might be happening ‘on the inside’ (their feelings, thoughts, desires, beliefs, intentions). We can think about mentalizing as ‘keeping minds in mind’.
!Mentalizing is an imaginative attitude, not a concrete skill
Mentalizing is not mindreading. Good mentalizing doesn not necessarily knowing what others are thinking or feeling, but in maintaining curiosity to find out. Mentalizing is an attitude which is inquiring and respectful of other people’s mental states, and aware of the limits of one’s knowledge of others. Mentalizing involves assuming: "there is something in her/his mind right now that means that it makes sense to her/him to do this..." and wondering "what might that something be?" and " How might I find out?"
!You can mentalize others or yourself
Mentalizing refers to wondering about your own mental states as well as others.
!Mentalizing involves embracing uncertainty
Mentalization-based therapies encourage clients and therapists alike to embrace uncertainty. Anna Freud writes about August Aichhorn, as a therapist and mentor:
>//So often teachers are in a hurry to get their students to know something, to have the right answers: a possession. Aichhorn knew how to scratch his head and say: Well, we can look at this boy in this way, but we can also look at him in that way, and there may be many other ways, too. He was challenging us: can you do the same – focus and refocus, shift your angle of vision, adjust your point of view?”//
!Mentalizating comes naturally to us
Our brains are are wired to be interested in intentions, and to attribute intentions to others.
!Mentalizing strengthens relationships
Understanding others and being understood by others is important for having fulfilling social interactions, and building strong, flexible, trusting and mutually rewarding relationships (secure attachments).
Mentalizing within relationships also allow us to build and organise our individual self identity, because we come to understand ourselves by seeing our mental states understoond and reflected back at us by others.
>“The task of coming to know oneself through the way one experiences being known, lies at the heart of self-organization.” - [[Karlen Lyons-Ruth|http://connects.catalyst.harvard.edu/Profiles/display/Person/3633]]
Mentalization-based therapies therefore foster mentalizing with the aim of improving a person’s //intra//personal //inter//personal wellbeing.
!Mentalizing is impaired under stress
It is hard to mentalize when our fundamental needs are not being met - for instance, when we feel anxious, unsafe, hungry, or exhausted. Mentalizing is an imaginative activity and involves embracing uncertainty. Of course, it is hard to be imaginative when our immediate needs are not being met. Threatening circumstances pull for certainty and action this is not the time for imagination, reflection and curiosity.

Having conducted [[court assessments|Specialist Assessment and Treatment Services]] for many years, it was evident that by the time families where parents have [[personality disorder/difficulties|Personality Disorder/Difficulties]] were assessed, it was too late; their children were already so damaged that the parents were not going to be able to parent them.
Yet, it was felt with support their children need not be removed but that their problems were not being addressed by current services in the ways that families were being managed. The main problem was that no service was comprehensive enough to look at all the problems that families with [[personality disorder/difficulties|Personality Disorder/Difficulties]] have. This reflected the [[poverty of the integrated response|Poverty of an integrated response]] and that families' were not receiving the support that they needed to parent their children adequately. This was combined with [[systemic failure|Systemic failure]] whereby professionals rather than think about the parent’s difficulty in engaging with services in [[attachment terms|attachment]] would react by referring families from one service to another and compound the experience of families' of service disintegration.
It was also thought that [[mentalization|Mentalization]] was a model that supports that integration to take place at both an individual and systematic level. This is because mentalization enables:
*identification of the difficulties that a parent has in their personality, in their parenting or in the child developing a capacity to mentalize in terms of their development.
*increased capacity of the system around the family to think or mentalize about the family’s experience and way parenting is happening.
This is why [[mentalization|Mentalization]] is central to the [[integration|Integration]] that is needed if effective help is to take place.
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